Devices and methods for gastrointestinal bypass

ABSTRACT

Devices and methods for gastrointestinal bypass are described. A gastrointestinal bypass device includes a gastrointestinal cuff and a gastrointestinal sleeve. The cuff may be configured to be attached in the esophagus, and may be sufficiently flexible to expand and collapse to conform with the inside of the esophagus to allow the esophagus to function substantially normally. The sleeve is configured to be coupled to the cuff, and may be made of a material that is floppy or flaccid but does not substantially expand radially.

BACKGROUND

Diabetes, heart disease, and other obesity-related conditions may betreated surgically with bariatric procedures such as jejuno-ilealbypass, jejuno-colic bypass, biliopancreatic diversion, gastric bypass,and gastroplasty. These procedures may be effective for weight controland treatment of chronic conditions. However, these procedures carrywith them substantial shortcomings, including the risk of infection andother risks accompanying surgery. Some of these procedures effectradical permanent changes to the gastrointestinal anatomy, thusforeclosing subsequent surgical intervention.

What is needed are devices and methods for gastrointestinal bypass thatavoid the risks associated with surgery by using non-surgicaltechniques. What is also needed are devices and methods forgastrointestinal bypass that allow for additional or revision proceduresto be performed. What is also needed are devices and methods forgastrointestinal bypass that are reversible.

SUMMARY

A gastrointestinal cuff device is described which includes a liner and aplurality of struts coupled to the liner at an angle to its longitudinalaxis. The struts are configured to twist the liner about itslongitudinal axis to prevent the liner from inverting when a retrogradeforce is applied to a distal portion of the liner.

Also described is a gastrointestinal cuff device which includes a linerand a plurality of struts coupled to the liner. The struts each have aplurality of holes for coupling the struts to the liner. The struts areconfigured to prevent the liner from inverting when a retrograde forceis applied to a distal portion of the liner.

Also described is a gastrointestinal cuff device which includes a linerhaving a scalloped edge with a plurality of peaks and valleys. The cuffalso includes a scaffold coupled to the liner. The scaffold has aplurality of proximal segments and distal segments coupled by connectingsegments. The proximal segments are positioned at the valleys. Thescaffold is configured to provide an outward bias to increaseconformance of the liner to an inside of an esophagus

Also described is a gastrointestinal cuff device which includes a linerand a plurality of struts coupled to the liner. The cuff also includes ascaffold coupled to the liner. The scaffold has a plurality of proximalsegments and distal segments coupled by connecting segments. The distalsegments are positioned across the struts. The scaffold is configured toprovide an outward bias to increase conformance of the liner to aninside of an esophagus.

Also described is a gastrointestinal sleeve device which includes acoupling and a tube configured to bypass food and liquids through astomach and/or part of an intestine. The sleeve also includes aradiopaque marker coupled to an inside surface of the tube. Theradiopaque marker is configured to maintain patency in the tube.

A tissue marking device is described, which includes a marking surfaceconfigured to contact tissue. The marking surface has a lumen and atleast one opening. The tissue marking device also includes a vacuumsource coupled to an outlet of the lumen. The vacuum source isconfigured to create a vacuum in the lumen and create a seal between theopening and the tissue. The tissue marking device also includes a dyesource coupled to an inlet of the lumen. The dye source contains a dye.

A tissue anchor delivery system is described, which includes a catheterhaving a central lumen. The catheter also has a side port formed in adistal portion of the catheter. The side port has a proximal side and adistal side. The tissue anchor delivery system also includes a sledslidably disposed in the central lumen. The sled has a sheathing channelwith a proximal opening configured to be positioned at a distal side ofthe side port. The tissue anchor delivery system also includes adelivery needle slidably disposed in the sheathing channel. The deliveryneedle has a needle lumen and tip pointed proximally. The deliveryneedle is configured to be advanced proximally through the distal sideof the side port. The tissue anchor delivery system also includes apushrod slidably disposed in the needle lumen.

BRIEF DESCRIPTION OF DRAWINGS

FIGS. 1A-1C show one embodiment of a gastrointestinal bypass device1000. FIG. 1D shows an enlarged view of a strut 1150.

FIGS. 2A-2C show another embodiment of a gastrointestinal bypass device2000. FIG. 2D shows an enlarged view of a hook 2160.

FIGS. 3A-3C show yet another embodiment of a gastrointestinal bypassdevice 3000. FIG. 3D shows still another embodiment of agastrointestinal bypass device 3000A. FIGS. 3E-3F show top views of cuff3100 in an open and a closed position. FIGS. 3G-3H show enlarged viewsof strut 3150. FIGS. 3I-3J show side views of cuff 3100 normally andsubjected to a retrograde force. FIGS. 3K-3L show other embodiments ofsleeve 3200.

FIGS. 4A-4B show one embodiment of a tissue anchor 1300. FIGS. 4C-4Dshow another embodiment of a tissue anchor 1300A.

FIGS. 5A-5C show one embodiment of a tissue marking device 1400.

FIGS. 6A-6D show one embodiment of a method for using tissue markingdevice 1400.

FIG. 7A shows one embodiment of a tissue marking device 2400.

FIGS. 7B-7D show various embodiments of marking surface 2420. FIG. 7Eshows various embodiments of openings 2426.

FIGS. 8A-8F show one embodiment of a method for using tissue markingdevice 2400.

FIGS. 9A-9C show one embodiment of a sleeve delivery device 1500.

FIGS. 9D-9G show one embodiment of a method for loading sleeve deliverydevice 1500.

FIGS. 10A-10C show another embodiment of a sleeve delivery device 2500.

FIGS. 10D-10G show one embodiment of a method for loading sleevedelivery device 2500.

FIGS. 11A-11C show yet another embodiment of a sleeve delivery device3500.

FIGS. 11D-11G show one embodiment of a method for loading sleevedelivery device 3500.

FIGS. 12A-12C show one embodiment of an anchor delivery device 1600.

FIGS. 13A-13E show one embodiment of a method for using anchor deliverydevice 1600.

FIGS. 14A-14C show one embodiment of a stent 1690.

FIGS. 15A-15G show another embodiment of an anchor delivery device 2600.

FIGS. 16A-16F show one embodiment of a method for using anchor deliverydevice 2600.

FIGS. 17A-17H show one embodiment of a method for implanting agastrointestinal bypass device 1000.

FIGS. 18A-18J show one embodiment of a method for implanting agastrointestinal bypass device 3000.

FIGS. 19A-19H show one embodiment of a method for exchanging a sleeve2200 of a gastrointestinal bypass device 2000.

DESCRIPTION

FIGS. 1A-1C show one embodiment of a gastrointestinal bypass device1000. FIG. 1A shows a perspective view of gastrointestinal bypass device1000. FIG. 1B shows an exploded view of gastrointestinal bypass device1000. FIG. 1C shows a cross-sectional view of gastrointestinal bypassdevice 1000. FIG. 1D shows an enlarged view of a strut 1150.

Gastrointestinal bypass device 1000 may include a gastrointestinal cuff1100 and a gastrointestinal sleeve 1200.

Cuff 1100 may be configured to be attached in the esophagus. Cuff 1100may be attached at or near the gastroesophageal junction. Alternatively,cuff 1100 may be attached proximal to the gastroesophageal junction, inthe proximal stomach, or at some other location. For example, cuff 1100may be attached within about 3 cm, 2.5 cm, 2 cm, 1.5 cm, 1 cm, 0.5 cm,above, below, or at the GEJ or squamo-columnar junction (SCJ or Z-line).Some non-limiting locations for attachment can be found, for example, inU.S. Pat. Pub. No. 2007/0198174 to Dann et al., which is herebyincorporated by reference in its entirety (e.g., at paras. [0131] to[0147]). Cuff 1100 may be sufficiently flexible to expand and collapseto conform with the inside of the esophagus. Cuff 1100 directs food andliquids into sleeve 1200, and provides a structure to which sleeve 1200may be attached. Cuff 1100 may be attached using tissue anchors.

Cuff 1100 may include a liner 1110, a plurality of anchor holes 1130,and a plurality of struts 1150.

Liner 1110 may include a proximal portion 1111, a distal portion 1112, alumen 1113, and a longitudinal axis 1114. Liner 1110 may be tubular andmay have a uniform width. Alternatively, liner 1110 may taper or changein width. Liner 1110 may be made of material that is flexible. Thisflexibility allows the attachment area, such as the lower esophagealsphincter, to open and close substantially normally. Liner 1110 may bemade of a material that is thin, allowing it to collapse into a smallerprofile. This smaller profile allows the attachment area, such as thelower esophageal sphincter, to close substantially normally, and alsohelps liner 1110 to be collapsed for delivery. Liner 1110 may include asingle layer of material. Alternatively, liner 1110 may include aplurality of layers. Liner 1110 may be at least semi-permeable toliquids and/or solids. This semi-permeability may allow some food toreach the stomach, and may help the stomach maintain some residualfunctionality. This semi-permeability may allow medications to reach thestomach. Liner 1110 may be made of DACRON or any other suitablematerial. In one embodiment, liner 1110 may have a length ofapproximately 20 mm to 80 mm. Liner 1110 may include a sleeve-couplingelement, e.g., suture holes 1115 formed at distal portion 1112.

A coupling mechanism, e.g., anchor holes 1130 may be formed at or nearproximal portion 1111 of liner 1110. Anchor holes 1130 are configured toreceive tissue anchors. Anchor holes 1130 may be marked with acontrasting color, radiopaque marker, or other means to aidvisualization. Anchor holes 1130 may be marked with stitching, ink, orother suitable marking. Anchor holes 1130 may be used as a placementtemplate for tissue anchors. Anchor holes 1130 may be evenly spacedabout a circumference of liner 1110. Evenly spaced anchor holes 1130 mayhelp to distribute forces among the tissue anchors, preventconcentration of forces in a small number of tissue anchors, and enhanceconformance of liner 1110 to an inside (e.g., luminal wall) of theesophagus. Alternatively, anchor holes 1130 may be spaced in any mannerabout a circumference of liner 1110. Anchor holes 1130 may besubstantially coplanar. Anchor holes 1130 may be arranged in a planesubstantially perpendicular to longitudinal axis 1114, or angled tolongitudinal axis 1114. A substantially coplanar arrangement may help toprevent concentration of forces in a small number of tissue anchors.Alternatively, anchor holes 1130 may be arranged in a staggered fashion.

Struts 1150 each include a proximal portion 1151 and a distal portion1152. Struts 1150 may be elongate and substantially straight.Alternatively, struts 1150 may be curved or any other suitable shape.Struts 1150 may be coupled to an inner surface of liner 1110.Alternatively, struts 1150 may be coupled to an outer surface of liner1110 or between layers of liner 1110 to reduce obstructions on an innersurface of liner 1110. Struts 1150 may be coupled to liner 1110longitudinally. Alternatively, struts 1150 may be coupled to liner 1110at an angle of 1 to 30 degrees or more with respect to longitudinal axis1114 of liner 1110. Struts 1150 may include a first attachment element,e.g., an anchor hole 1154 at or near proximal portion 1151. Anchor holes1154 of struts 1150 may be aligned with anchor holes 1130 of liner 1110.Anchor holes 1154 of struts 1150 may reinforce anchor holes 1130 ofliner 1110 and prevent tissue anchors from pulling through. Struts 1150may include a second attachment element, e.g., suture holes 1155, andstruts 1150 may be coupled to liner 1110 with sutures stitched throughsuture holes 1155 and liner 1110. Alternatively, struts 1150 may becoupled to liner 1110 with adhesives, thermal bonding, ultrasonic orlaser welding, pockets formed between layers of liner 1110, or othersuitable ways. Struts 1150 may have a uniform cross-section.Alternatively, struts 1150 may have a non-uniform cross-section whichvaries wider, narrower, thicker, and/or thinner. For example, struts1150 may each have a proximal portion 1151 and/or a distal portion 1152which are thinner. This thinner cross-section allows proximal portion1151 and/or distal portion 1152 to be more flexible. Struts 1150 may bemade of a plastic such as PEEK, a metal, or any other suitable material.

Struts 1150 may reduce longitudinal stretching of liner 1110. Progradeforces such as peristaltic forces at distal portion 1112 of liner 1110are transferred by struts 1150 to anchor holes 1154 and tissue anchors,to advantageously redistribute forces and minimize focal wear or failurepoints. Struts 1150 may also prevent inversion of liner 1110. Retrogradeforces such as vomiting or retching forces at distal portion 1112 ofliner 1110 are resisted by struts 1150, helping to maintain liner 1110in proper implanted position.

Sleeve 1200 is configured to be coupled to cuff 1100, either in anintegrally formed or removably coupled manner. Sleeve 1200 directs foodand liquids into the intestine. Sleeve 1200 may include a coupling 1210and a tube 1250.

Coupling 1210 directs food and liquids from cuff 1100 to tube 1250.Coupling 1210 includes a proximal portion 1211, a distal portion 1212,and a lumen 1213. A coupling element, e.g., suture holes 1215 may beformed at or near proximal portion 1211 to allow coupling 1210 becoupled with sutures to a complementary cuff-coupling element, e.g.,suture holes 1115 in liner 1110. Proximal portion 1211 may have a widththat is the same or substantially the same as liner 1110, or in someembodiments taper down in width to restrict the flow of food and liquidsthrough coupling 1210, which may help to create a feeling of fullness.Distal portion 1212 may have a uniform width. Alternatively, proximalportion 1211 and distal portion 1212 may have a uniform width. Coupling1210 may be made of a material that is flexible, but does not stretchsubstantially in a radial or longitudinal direction. Coupling 1210 maybe made of a polyurethane elastomer such as PELLETHANE, or any othersuitable material.

Tube 1250 includes a proximal portion 1251, a distal portion 1252, and alumen 1253. Proximal portion 1251 of tube 1250 may be coupled to distalportion 1212 of coupling 1210 with an interference fit, heat bonded,and/or other suitable methods. Tube 1250 may have a uniform width.Alternatively, tube 1250 may taper or change in width. Tube 1250 mayallow food and liquids to bypass the stomach and/or part of theintestine. Tube 1250 may allow foods and liquids to be bypassed into theduodenum, jejunum, or other part of the intestine. In one embodiment,tube 1250 may have a length of approximately 80 cm to 120 cm, a diameterof approximately 15 mm to 25 mm, and/or a thickness of about 0.05 mm toabout 0.5 mm, such as about 0.15 mm.

Tube 1250 may be made of a material that is floppy or flaccid, but doesnot stretch substantially in a radial direction. Thus, tube 1250 may beflexible and compliant inwardly to allow peristaltic forces to act onits contents, but will not balloon outwardly. Tube 1250 may also notstretch substantially in a longitudinal direction. Tube 1250 may be madeof a polyurethane elastomer such as PELLETHANE, or any other suitablematerial. Tube 1250 may be impermeable or semi-permeable. Tube 1250 mayallow nutrients and medications inside tube 1250 to pass outward.Alternatively or in addition, tube 1250 may allow digestive juices andhormones outside tube 1250 to pass inward. Tube 1250 or portions of tube1250 may be biodegradable. Tube 1250 with a plurality of biodegradableportions may be configured such that each portion degrades at adifferent rate.

Tube 1250 may include one or more coatings to resist calcification,deliver medications, provide lubriciousness, and/or provide otherdesired properties. Tube 1250 may include an electrical stimulationelement to resist calcification and promote motility and satiety.Various electrical stimulation elements that can be utilized or modifiedfor use with the systems and methods disclosed herein are described, forexample, in U.S. Pat. No. 7,881,797 to Griffin et al., which is herebyincorporated by reference in its entirety. Tube 1250 may be made up ofone or more sections which may be coupled or uncoupled to adjust alength of tube 1250. Tube 1250 may include one, two, or more additionallumens interior to, exterior to, or within walls of tube 1250 fordelivery of medications, access for imaging devices for visualmonitoring, and access for diagnostic sampling. Tube 1250 may haveadditional lumens which open at different points along the length oftube 1250 for targeted delivery or access.

Tube 1250 may include a radiopaque marker 1254. Radiopaque marker 1254may be one or more longitudinal stripes which run along all or part ofthe length of tube 1250. Radiopaque marker 1254 may be configured tohelp prevent or reduce kinking and twisting of tube 1250. For example,radiopaque marker 1254 may be thicker and/or wider toward proximalportion 1251 of tube 1250, where kinking and twisting may be morepronounced. Alternatively, radiopaque marker 1254 may be a helicalstripe, circumferential bands, or other suitable configuration.Radiopaque marker 1254 may be coupled to an inside surface of tube 1250to help maintain at least some patency of lumen 1253 and prevent lumen1253 from closing completely when tube 1250 is kinked or twisted.Alternatively, radiopaque marker 1254 may be coupled to an outsidesurface of tube 1250. Various embodiments, features, materials andparameters of cuffs, sleeves, anchors, and other components that can beused or modified for use with those disclosed herein are described, forexample, in the following patents and publications, each of which areincorporated by reference in their entireties: U.S. Pat. Pub. No.2007/0198074 to Dann et al., U.S. Pat. No. 8,070,743 to Kagan et al.,U.S. Pat. Pub. No. 2009/0149871 to Kagan et al., U.S. Pat. Pub. No.2004/0092892 to Kagan et al., U.S. Pat. Pub. No. 2006/0155375 to Kaganet al., U.S. Pat. Pub. No. 2006/0015125 to Swain, U.S. Pat. Pub. No.2006/0020254 to von Hoffmann, U.S. Pat. No. 8,118,774 to Dann et al.,U.S. Pat. Pub. No. 2009/0012553 to Swain et al., U.S. Pat. Pub. No.2009/0012544 to Thompson et al., and U.S. Pat. Pub. No. 2009/0012541 toDahl et al.

Tube 1250 may include one, two, three, or more tails 1255 at distalportion 1252. Tails 1255 may be folded over each other and cinched witha grasping element, such as a loop snare, to seal distal portion 1255 oftube 1250 during deployment of sleeve 1200. Tails 1255 may be asdescribed, for example, in U.S. Pat. No. 8,118,774 to Dann et al., whichis hereby incorporated by reference in its entirety.

FIGS. 2A-2C show another embodiment of a gastrointestinal bypass device2000. FIG. 2A shows a perspective view of gastrointestinal bypass device2000. FIG. 2B shows an exploded view of gastrointestinal bypass device2000. FIG. 2C shows a cross-sectional view of gastrointestinal bypassdevice 2000. FIG. 2D shows an enlarged view of a hook 2160.

Gastrointestinal bypass device 2000 may include a gastrointestinal cuff2100 and a gastrointestinal sleeve 2200.

Cuff 2100 may be configured to be attached in the esophagus. Cuff 2100may be attached at or near the gastroesophageal junction. Alternatively,cuff 2100 may be attached proximal to the gastroesophageal junction, inthe proximal stomach, or at some other location. For example, cuff 2100may be attached within about 3 cm, 2.5 cm, 2 cm, 1.5 cm, 1 cm, 0.5 cm,above, below, or at the GEJ or squamo-columnar junction (SCJ or Z-line).Some non-limiting locations for attachment can be found, for example, inU.S. Pat. Pub. No. 2007/0198174 to Dann et al., which is herebyincorporated by reference in its entirety (e.g., at paras. [0131] to[0147]). Cuff 2100 may be sufficiently flexible to expand and collapseto conform with the inside of the esophagus. Cuff 2100 directs food andliquids into sleeve 2200, and provides a structure to which sleeve 2200may be attached. Cuff 2100 may be attached using tissue anchors.

Cuff 2100 may include a liner 2110, a plurality of anchor holes 2130, aretainer 2140, a plurality of struts 2150, and one or more hooks 2160.

Liner 2110 may include a proximal portion 2111, a distal portion 2112, alumen 2113, and a longitudinal axis 2114. Liner 2110 may be tubular andmay have a uniform width. Alternatively, liner 2110 may taper or changein width. Liner 2110 may be made of material that is flexible. Thisflexibility allows the attachment area, such as the lower esophagealsphincter, to open and close substantially normally. Liner 2110 may bemade of a material that is thin, allowing it to collapse into a smallerprofile. This smaller profile allows the attachment area, such as thelower esophageal sphincter, to close substantially normally, and alsohelps liner 2110 to be collapsed for delivery. Liner 2110 may include asingle layer of material. Alternatively, liner 2110 may include aplurality of layers. Liner 2110 may be at least semi-permeable toliquids and/or solids. This semi-permeability may allow some food toreach the stomach, and may help the stomach maintain some residualfunctionality. This semi-permeability may allow medications to reach thestomach. Liner 2110 may be made of DACRON or any other suitablematerial. In one embodiment, liner 2110 may have a length ofapproximately 20 mm to 80 mm.

A coupling mechanism, e.g. anchor holes 2130 may be formed at or nearproximal portion 2111 of liner 2110. Anchor holes 2130 are configured toreceive tissue anchors. Anchor holes 2130 may be marked with acontrasting color, radiopaque marker, or other means to aidvisualization. Anchor holes 2130 may be marked with stitching, ink, orother suitable marking. Anchor holes 2130 may be used as a placementtemplate for tissue anchors. Anchor holes 2130 may be evenly spacedabout a circumference of liner 2110. Evenly spaced anchor holes 2130 mayhelp to distribute forces among the tissue anchors, preventconcentration of forces in a small number of tissue anchors, and enhanceconformance of liner 2110 to an inside (e.g., luminal wall) of theesophagus. Alternatively, anchor holes 2130 may be spaced in any mannerabout a circumference of liner 2110. Anchor holes 2130 may besubstantially coplanar. Anchor holes 2130 may be arranged in a planesubstantially perpendicular to longitudinal axis 2114, or angled tolongitudinal axis 2114. A substantially coplanar arrangement may help toprevent concentration of forces in a small number of tissue anchors.Alternatively, anchor holes 2130 may be arranged in a staggered fashion.

Retainer 2140 may be coupled to distal portion 2112 of liner 2110.Retainer 2140 may be collapsible radially inwardly but not expandableradially outwardly. Retainer 2140 may be a circumferential channelformed in distal portion 2112 of liner 2110 by one or more folds 2141.Folds 2141 may be secured by a suture 2142, adhesive, or other means.Folds 2141 may be made more rigid by applying a stiffening substance todistal portion 2112 and/or folds 2141. The stiffening substance may besilicone or other suitable substance. Alternatively, retainer 2140 maybe made of plastic or other suitable material, and coupled to distalportion 2112 of liner 2110.

Struts 2150 each include a proximal portion 2151 and a distal portion2152. Struts 2150 may be elongate and substantially straight.Alternatively, struts 2150 may be curved or any other suitable shape.Struts 2150 may be coupled to an inner surface of liner 2110.Alternatively, struts 2150 may be coupled to an outer surface of liner2110 or between layers of liner 2110 to reduce obstructions on an innersurface of liner 2110. Struts 2150 may be coupled to liner 2110longitudinally. Alternatively, struts 2150 may be coupled to liner 2110at an angle of 1 to 30 degrees or more with respect to longitudinal axis2114 of liner 2110. Struts 2150 may include a first attachment element,e.g., an anchor hole 2154 at or near proximal portion 2151. Anchor holes2154 of struts 2150 may be aligned with anchor holes 2130 of liner 2110.Anchor holes 2154 of struts 2150 may reinforce anchor holes 2130 ofliner 2110 and prevent tissue anchors from pulling through. Struts 2150may include a second attachment element, e.g., suture holes 2155, andstruts 2150 may be coupled to liner 2110 with sutures stitched throughsuture holes 2155 and liner 2110. Alternatively, struts 2150 may becoupled to liner 2110 with adhesives, thermal bonding, ultrasonic orlaser welding, pockets formed between layers of liner 2110, or othersuitable ways. Struts 2150 may have a uniform cross-section.Alternatively, struts 2150 may have a non-uniform cross-section whichvaries wider, narrower, thicker, and/or thinner. For example, struts2150 may each have a proximal portion 2151 and/or a distal portion 2152which are thinner. This thinner cross-section allows proximal portion2151 and/or distal portion 2152 to be more flexible. Struts 2150 may bemade of a plastic such as PEEK, a metal, or any other suitable material.

Struts 2150 may reduce longitudinal stretching of liner 2110. Progradeforces such as peristaltic forces at distal portion 2112 of liner 2110are transferred by struts 2150 to anchor holes 2154 and tissue anchors,to advantageously redistribute forces and minimize focal wear or failurepoints. Struts 2150 may also prevent inversion of liner 2110. Retrogradeforces such as vomiting or retching forces at distal portion 2112 ofliner 2110 are resisted by struts 2150, helping to maintain liner 2110in proper implanted position.

Hooks 2160 may each include a proximal portion 2161 and a distal portion2162. Proximal portion 2161 may be coupled to distal portion 2152 ofstrut 2150. Hooks 2160 may include one or more suture holes 2164 forstitching to liner 2110 and/or distal portion 2152 of strut 2150.Alternatively, hooks 2160 may be coupled to liner 2110 or one or morestruts 2150 with an adhesive or other suitable methods. Alternatively,hooks 2160 may be formed as part of one or more struts 2150. Hooks 2160may each include a retainer 2165 and a barb 2166. Distal portions 2162may be configured so that they do not substantially protrude beyondstruts 2150 into an interior of liner 2110. Distal portion 2112 of liner2110 may be enlarged in diameter or otherwise configured to accommodatehooks 2160.

Sleeve 2200 is configured to be coupled to cuff 2100, either in anintegrally formed or removably coupled manner. Sleeve 2200 directs foodand liquids into the intestine. Sleeve 2200 may include a coupling 2210,a ring 2240, a tube 2250, and a halo 2260.

Coupling 2210 directs food and liquids from cuff 2100 to tube 2250.Coupling 2210 includes a proximal portion 2211, a distal portion 2212,and a lumen 2213. Drawstring holes 2215 may be formed at or nearproximal portion 2211. Proximal portion 2211 may have a width that isthe same or substantially the same as liner 2110, or in some embodimentstaper down in width to restrict the flow of food and liquids throughcoupling 2210, which may help to create a feeling of fullness. Distalportion 2212 may have a uniform width. Alternatively, proximal portion2211 and distal portion 2212 may have a uniform width. Coupling 2210 maybe made of a material that is flexible, but does not stretchsubstantially in a radial or longitudinal direction. Coupling 2210 maybe made of a polyurethane elastomer such as PELLETHANE, or any othersuitable material.

Ring 2240 may be coupled to proximal portion 2211 of coupling 2210. Ring2240 may be a thickened portion of coupling 2210, or a separatestructure operably attached to coupling 2210. Ring 2240 may besufficiently flexible to deform inwardly, but sufficiently rigid tospring back to its original shape. Ring 2240 is configured to interfacewith retainer 2140. Ring 2240 may have an interference fit with retainer2140, or other form of attachment. Sleeve 2200 is thus coupled to cuff2100 by ring 2240 and retainer 2140. Sleeve 2200 can be exchanged for anew, second sleeve having the same or one, two, or more differingproperties by inwardly deforming ring 2240 and removing sleeve 2200.Ring 2240 may be inwardly deformed using a drawstring 2241 threadedthrough drawstring holes 2215. Other properties of sleeves, cuffs,cuff-sleeve attachment interfaces, and sleeve exchange methods can befound, for example, in U.S. Pat. Pub. No. 2007/0198074 to Dann et al.,and U.S. Pat. No. 8,070,743 to Kagan et al., each of which are herebyincorporated by reference in their entireties.

Tube 2250 includes a proximal portion 2251, a distal portion 2252, and alumen 2253. Proximal portion 2251 of tube 2250 may be coupled to distalportion 2212 of coupling 2210 with an interference fit, heat bonded,and/or other suitable methods. Tube 2250 may have a uniform width.Alternatively, tube 2250 may taper or change in width. Tube 2250 mayallow food and liquids to bypass the stomach and/or part of theintestine. Tube 2250 may allow foods and liquids to be bypassed into theduodenum, jejunum, or other part of the intestine. In one embodiment,tube 2250 may have a length of approximately 80 cm to 120 cm, a diameterof approximately 15 mm to 25 mm, and/or a thickness of about 0.05 mm toabout 0.5 mm, such as about 0.15 mm.

Tube 2250 may be made of a material that is floppy or flaccid, but doesnot stretch substantially in a radial direction. Thus, tube 2250 may beflexible and compliant inwardly to allow peristaltic forces to act onits contents, but will not balloon outwardly. Tube 2250 may also notstretch substantially in a longitudinal direction. Tube 2250 may be madeof a polyurethane elastomer such as PELLETHANE, or any other suitablematerial. Tube 2250 may be impermeable or semi-permeable. Tube 2250 mayallow nutrients and medications inside tube 2250 to pass outward.Alternatively or in addition, tube 2250 may allow digestive juices andhormones outside tube 2250 to pass inward. Tube 2250 or portions of tube2250 may be biodegradable. Tube 2250 with a plurality of biodegradableportions may be configured such that each portion degrades at adifferent rate.

Tube 2250 may include one or more coatings to resist calcification,deliver medications, provide lubriciousness, and/or provide otherdesired properties. Tube 2250 may include an electrical stimulationelement to resist calcification and promote motility and satiety.Various electrical stimulation elements that can be utilized or modifiedfor use with the systems and methods disclosed herein are described, forexample, in U.S. Pat. No. 7,881,797 to Griffin et al., which is herebyincorporated by reference in its entirety. Tube 2250 may be made up ofone or more sections which may be coupled or uncoupled to adjust alength of tube 2250. Tube 2250 may include one, two, or more additionallumens interior to, exterior to, or within walls of tube 2250 fordelivery of medications, access for imaging devices for visualmonitoring, and access for diagnostic sampling. Tube 2250 may haveadditional lumens which open at different points along the length oftube 2250 for targeted delivery or access.

Tube 2250 may include a radiopaque marker 2254. Radiopaque marker 2254may be one or more longitudinal stripes which run along all or part ofthe length of tube 2250. Radiopaque marker 2254 may be configured tohelp prevent or reduce kinking and twisting of tube 2250. For example,radiopaque marker 2254 may be thicker and/or wider toward proximalportion 2251 of tube 2250, where kinking and twisting may be morepronounced. Alternatively, radiopaque marker 2254 may be a helicalstripe, circumferential bands, or other suitable configuration.Radiopaque marker 2254 may be coupled to an inside surface of tube 2250to help maintain at least some patency of lumen 2253 and prevent lumen2253 from closing completely when tube 2250 is kinked or twisted.Alternatively, radiopaque marker 2254 may be coupled to an outsidesurface of tube 2250. Various embodiments, features, materials andparameters of cuffs, sleeves, anchors, and other components that can beused or modified for use with those disclosed herein are described, forexample, in the following patents and publications, each of which areincorporated by reference in their entireties: U.S. Pat. Pub. No.2007/0198074 to Dann et al., U.S. Pat. No. 8,070,743 to Kagan et al.,U.S. Pat. Pub. No. 2009/0149871 to Kagan et al., U.S. Pat. Pub. No.2004/0092892 to Kagan et al., U.S. Pat. Pub. No. 2006/0155375 to Kaganet al., U.S. Pat. Pub. No. 2006/0015125 to Swain, U.S. Pat. Pub. No.2006/0020254 to von Hoffmann, U.S. Pat. No. 8,118,774 to Dann et al.,U.S. Pat. Pub. No. 2009/0012553 to Swain et al., U.S. Pat. Pub. No.2009/0012544 to Thompson et al., and U.S. Pat. Pub. No. 2009/0012541 toDahl et al.

Tube 2250 may include one, two, three, or more tails 2255 at distalportion 2252. Tails 2255 may be folded over each other and cinched witha grasping element, such as a loop snare, to seal distal portion 2255 oftube 2250 during deployment of sleeve 2200. Tails 2255 may be asdescribed, for example, in U.S. Pat. No. 8,118,774 to Dann et al., whichis hereby incorporated by reference in its entirety.

Halo 2260 may be coupled to proximal portion 2211 of coupling 2210 byone or more standoffs 2261. Standoffs 2261 may be coupled to proximalportion 2211 of coupling 2210 using an adhesive or other suitablemethods. Halo 2260 may be made of suture or other suitable material.Halo 2260 is configured to be coupled to hooks 2160. Halo 2260 and hooks2160 may provide a primary or backup coupling between sleeve 2200 andcuff 2100. Halo 2260 and hooks 2160 are configured to keep sleeve 2200coupled to cuff 2100 if the coupling between retainer 2140 and ring 2240should fail. Halo 2260 may be cut between standoffs 2261 to releasesleeve 2200 for removal or exchange. Distal portion 2112 of liner 2110may be enlarged in diameter or otherwise configured to accommodate halo2260 and standoffs 2261.

FIGS. 3A-3C show yet another embodiment of a gastrointestinal bypassdevice 3000. FIG. 3A shows a perspective view of gastrointestinal bypassdevice 3000. FIG. 3B shows an exploded view of gastrointestinal bypassdevice 3000. FIG. 3C shows a cross-sectional view of gastrointestinalbypass device 3000. FIG. 3D shows still another embodiment of agastrointestinal bypass device 3000A. FIGS. 3E-3F show top views of cuff3100 in an open and a closed position. FIGS. 3G-3H show enlarged viewsof strut 3150. FIGS. 3I-3J show side views of cuff 3100 normally andsubjected to a retrograde force. FIGS. 3K-3L show other embodiments ofsleeve 3200.

Gastrointestinal bypass device 3000 may include a gastrointestinal cuff3100 and a gastrointestinal sleeve 3200.

Cuff 3100 may be configured to be attached in the esophagus. Cuff 3100may be attached at or near the gastroesophageal junction. Alternatively,cuff 3100 may be attached proximal to the gastroesophageal junction, inthe proximal stomach, or at some other location. For example, cuff 3100may be attached within about 3 cm, 2.5 cm, 2 cm, 1.5 cm, 1 cm, 0.5 cm,above, below, or at the GEJ or squamo-columnar junction (SCJ or Z-line).Some non-limiting locations for attachment can be found, for example, inU.S. Pat. Pub. No. 2007/0198174 to Dann et al., which is herebyincorporated by reference in its entirety (e.g., at paras. [0131] to[0147]). Cuff 3100 may be sufficiently flexible to expand and collapseto conform with the inside of the esophagus. Cuff 3100 directs food andliquids into sleeve 3200, and provides a structure to which sleeve 3200may be attached. Cuff 3100 may be attached using tissue anchors.

Cuff 3100 may include a liner 3110, an edge with one, two, or moreprojections, e.g., a scalloped edge 3120, a plurality of anchor holes3130, a retainer 3140, a plurality of struts 3150, one or moreattachment holes 3160, and a scaffold 3170.

Liner 3110 may include a proximal portion 3111, a distal portion 3112, alumen 3113, and a longitudinal axis 3114. Liner 3110 may be tubular andmay have a uniform width. Alternatively, liner 3110 may taper or changein width. Liner 3110 may be made of material that is flexible. Thisflexibility allows the attachment area, such as the lower esophagealsphincter, to open and close substantially normally. Liner 3110 may bemade of a material that is thin, allowing it to collapse into a smallerprofile. This smaller profile allows the attachment area, such as thelower esophageal sphincter, to close substantially normally, and alsohelps liner 3110 to be collapsed for delivery. Liner 3110 may include aninner layer 3116 and an outer layer 3117. Alternatively, liner 3110 mayinclude a single layer of material, or any number of layers. Inner layer3116 and outer layer 3117 may be sealed at proximal portion 3111 with anedge seal 3118. Edge seal 3118 may be silicone or other suitablematerial. Edge seal 3118 may be radiopaque. Alternatively, inner layer3116 and outer layer 3117 may be formed from a single layer of materialfolded over. Inner layer 3116 and outer layer 3117 may be at leastpartially coupled together by sutures, thermal bonding, ultrasonic orlaser welding, or other ways. Liner 1110 may be at least semi-permeableto liquids and/or solids. This semi-permeability may allow some food toreach the stomach, and may help the stomach maintain some residualfunctionality. This semi-permeability may allow medications to reach thestomach. Liner 3110 may be made of DACRON or any other suitablematerial. In one embodiment, liner 3110 may have a length ofapproximately 20 mm to 80 mm.

Scalloped edge 3120 may include a plurality of peaks 3121 and valleys3122 formed at the edge of proximal portion 3111 of liner 3110. Peaks3121 and valleys 3122 may be of uniform shape and size. Alternatively,peaks 3121 and valleys 3122 may be of varying shapes and sizes.Scalloped edge 3120 allows peaks 3121 to open wider than the rest ofliner 3110, as shown in FIG. 3E. This enhances conformance of scallopededge 3120 to an inside of the esophagus and reduces the amount of foodand liquids which pass outside of scalloped edge 3120 and into thestomach (and thus outside of the cuff and sleeve). Reducing the amountof food or liquid that passes outside of the cuff and sleeve can in somecases advantageously improve clinical endpoints (e.g., improved weightloss, improved glyemic, lipid profile, blood pressure, etc.). Valleys3122 may include a webbing which may be thinner than liner 3110.Scalloped edge 3120 reduces bunching of liner 3110 when the esophagus isclosed, and reduces the profile of liner 3110 when the esophagus isclosed, as shown in FIG. 3F.

A coupling mechanism, e.g., anchor holes 3130 may be formed in the peaks3121 of scalloped edge 3120. Anchor holes 3130 are configured to receivetissue anchors. Anchor holes 3130 may be marked with a contrastingcolor, radiopaque marker, or other means to aid visualization. Anchorholes 3130 may be marked with stitching, ink, or other suitable marking.Anchor holes 3130 may be used as a placement template for tissueanchors. Anchor holes 3130 may be evenly spaced about a circumference ofliner 3110. Evenly spaced anchor holes 3130 may help to distributeforces among the tissue anchors, prevent concentration of forces in asmall number of tissue anchors, and enhance conformance of liner 3110 toan inside (e.g., luminal wall) of the esophagus. Alternatively, anchorholes 3130 may be spaced in any manner about a circumference of liner3110. Anchor holes 3130 may be substantially coplanar. Anchor holes 3130may be arranged in a plane substantially perpendicular to longitudinalaxis 3114, or angled to longitudinal axis 3114. A substantially coplanararrangement may help to prevent concentration of forces in a smallnumber of tissue anchors. Alternatively, anchor holes 3130 may bearranged in a staggered fashion.

Retainer 3140 may be coupled to distal portion 3112 of liner 3110.Retainer 3140 may be collapsible radially inwardly but not expandableradially outwardly. Retainer 3140 may be a circumferential channelformed in distal portion 3112 of liner 3110 by one or more folds 3141.Folds 3141 may be secured by a suture 3142, adhesive, or other means.Folds 3141 may be made more rigid by applying a stiffening substance todistal portion 3112 and/or folds 3141. The stiffening substance may besilicone or other suitable substance. Alternatively, retainer 3140 maybe made of plastic or other suitable material, and coupled to distalportion 3112 of liner 3110.

Struts 3150 each include a proximal portion 3151 and a distal portion3152. Struts 3150 may be elongate and substantially straight.Alternatively, struts 3150 may be curved or any other suitable shape.Struts 3150 may be coupled to liner 3110 between layers of liner 3110.Alternatively, struts 3150 may be coupled to an inner surface or anouter surface of liner 3110. Struts 3150 may be coupled to liner 3110 atan angle of 1 to 30 degrees or more with respect to longitudinal axis3114 of liner 3110. Alternatively, struts 3150 may be coupled to liner3110 longitudinally without an angle. Struts 3150 may include a firstattachment element, e.g., an anchor eyelet 3154 at proximal portion3151. Struts 3150 may include a second attachment element, e.g., asuture eyelet 3155 at distal portion 3152. Anchor eyelets 3154 may bealigned with anchor holes 3130 of liner 3110 to reinforce anchor holes3130 of liner 3110 and prevent tissue anchors from pulling through.Struts 3150 may be coupled to liner 3110 with pockets formed bystitching together layers of liner 3110, and stitching through sutureeyelets 3155. Alternatively, struts 3150 may be coupled to liner 3110with sutures, adhesives, thermal bonding, ultrasonic or laser welding,or other suitable ways. Struts 3150 may have a uniform cross-section.Alternatively, struts 3150 may have a non-uniform cross-section whichvaries wider, narrower, thicker, and/or thinner. For example, struts3150 may have a proximal portion 3151 and/or a distal portion 3152 whichare thinner and/or wider, as shown in FIGS. 3G-3H. This varyingcross-section allows proximal portion 3151 and/or distal portion 3152 tobe more flexible. Struts 3150 may include a notch 3157. Struts 3150 maybe made of a plastic such as PEEK, a metal, or any other suitablematerial.

Struts 3150 may reduce longitudinal stretching of liner 3110. Progradeforces such as peristaltic forces at distal portion 3112 of liner 3110are transferred by struts 3150 to anchor eyelets 3154 and tissueanchors, to advantageously redistribute forces and minimize focal wearor failure points. Struts 3150 may also prevent inversion of liner 3110.Retrograde forces such as vomiting or retching forces at distal portion3112 of liner 3110 cause liner 3110 and angled struts 3150 to twist orcorkscrew about longitudinal axis 3114 and prevents inversion of liner3110, as shown in FIGS. 3I-3J, helping to maintain liner 3110 in properimplanted position. This twisting or corkscrewing may also at leastpartially close lumen 3113 of liner 3110.

Attachment holes 3160 may be formed at distal portion 3112 of liner3110. Attachment holes 3160 may be marked with a contrasting color toaid visualization. Attachment holes 3160 may be marked with stitching,ink, or other suitable marking.

Scaffold 3170 may be coupled to liner 3110 between layers of liner.Alternatively, scaffold may be coupled to an inner surface or an outersurface of liner 3110. Scaffold 3170 may be coupled to liner 3110 withsutures, adhesives, or other suitable ways. Scaffold 3170 may have anydesired wall pattern, and in some embodiments resemble a sawtooth wave,sine wave, square wave, triangle wave, or other wave. Scaffold 3170 mayinclude a plurality of proximal segments 3171 and a plurality of distalsegments 3172 connected by a plurality of connecting segments 3173.Alternatively, scaffold 3170 may be a mesh, ring, or other suitabledevice. Scaffold 3170 may be coupled to struts 3150, or formedintegrally with struts 3150. Scaffold 3170 may cross each strut 3150through notch 3157.

Scaffold 3170 provides an outward bias to enhance conformance of liner3110 to the luminal wall of the esophagus. This outward bias may belarge enough to open liner 3110 when the esophagus opens, but not solarge as to prevent the esophagus from closing. Scaffold 3170 is notnecessarily meant to hold cuff 3100 in the esophagus. Scaffold 3170 mayhave a geometry, such as length and thickness, selected to create adesired amount of outward bias. Scaffold 3170 may be made of a materialselected to create a desired amount of outward bias. Scaffold 3170 maybe made of plastic such as PEEK, metal, or any other suitable material.Proximal segments 3171 may be placed at or near valleys 3122. Thisplacement positions outward bias at valleys 3122. Any portion ofscaffold 3170 may be placed across struts 3150. The placement ofscaffold 3170 across struts 3150 may be selected to create a desiredamount of outward bias. For example, distal segments 3172 may be placedacross struts 3150. This placement provides a pivot point for connectingsegments 3173 of scaffold 3170. This placement may also fold or rotatepeaks 3121 when liner 3110 closes, resulting in a smaller closedprofile, as shown in FIGS. 3E-3F.

Sleeve 3200 is configured to be coupled to cuff 3100, either in anintegrally formed or removably coupled manner. Sleeve 3200 directs foodand liquids into the intestine. Sleeve 3200 may include a coupling 3210,a ring 3240, a tube 3250, and one or more attachment elements 3260.

Coupling 3210 directs food and liquids from cuff 3100 to tube 3250.Coupling 3210 includes a proximal portion 3211, a distal portion 3212,and a lumen 3213. Drawstring holes 3215 may be formed at or nearproximal portion 3211. Proximal portion 3211 may have a width that isthe same or substantially the same as liner 3110, or in some embodimentstaper down in width to restrict the flow of food and liquids throughcoupling 3210, which may help to create a feeling of fullness. Distalportion 3212 may have a uniform width. Alternatively, proximal portion3211 and distal portion 3212 may have a uniform width. Coupling 3210 maybe made of a material that is flexible, but does not stretchsubstantially in a radial or longitudinal direction. Coupling 3210 maybe made of a polyurethane elastomer such as PELLETHANE, or any othersuitable material.

Ring 3240 may be coupled to proximal portion 3211 of coupling 3210. Ring3240 may be a thickened portion of coupling 3210, or a separatestructure operably attached to coupling 3210. Ring 3240 may besufficiently flexible to deform inwardly, but sufficiently rigid tospring back to its original shape. Ring 3240 is configured to interfacewith retainer 3140. Ring 3240 may have an interference fit with retainer3140, or other form of attachment. Sleeve 3200 is thus coupled to cuff3100 by ring 3240 and retainer 3140. Sleeve 3200 can be exchanged for anew, second sleeve having the same or one, two, or more differingproperties by inwardly deforming ring 3240 and removing sleeve 3200.Ring 3240 may be inwardly deformed using a drawstring 3241 threadedthrough drawstring holes 3215. Other properties of sleeves, cuffs,cuff-sleeve attachment interfaces, and sleeve exchange methods can befound, for example, in U.S. Pat. Pub. No. 2007/0198074 to Dann et al.,and U.S. Pat. No. 8,070,743 to Kagan et al., each of which are herebyincorporated by reference in their entireties.

Tube 3250 includes a proximal portion 3251, a distal portion 3252, and alumen 3253. Proximal portion 3251 of tube 3250 may be coupled to distalportion 3212 of coupling 3210 with an interference fit, heat bonded,and/or other suitable methods. Tube 3250 may have a uniform width.Alternatively, tube 3250 may taper or change in width. Tube 3250 mayallow food and liquids to bypass the stomach and/or part of theintestine. Tube 3250 may allow foods and liquids to be bypassed into theduodenum, jejunum, or other part of the intestine. In one embodiment,tube 3250 may have a length of approximately 80 cm to 120 cm, a diameterof approximately 15 mm to 25 mm, and/or a thickness of about 0.05 mm toabout 0.5 mm, such as about 0.15 mm.

Tube 3250 may be made of a material that is floppy or flaccid, but doesnot stretch substantially in a radial direction. Thus, tube 3250 may beflexible and compliant inwardly to allow peristaltic forces to act onits contents, but will not balloon outwardly. Tube 3250 may also notstretch substantially in a longitudinal direction. Tube 3250 may be madeof a polyurethane elastomer such as PELLETHANE, or any other suitablematerial. Tube 3250 may be impermeable or semi-permeable. Tube 3250 mayallow nutrients and medications inside tube 3250 to pass outward.Alternatively or in addition, tube 3250 may allow digestive juices andhormones outside tube 3250 to pass inward. Tube 3250 or portions of tube3250 may be biodegradable. Tube 3250 with a plurality of biodegradableportions may be configured such that each portion degrades at adifferent rate.

Tube 3250 may include one or more coatings to resist calcification,deliver medications, provide lubriciousness, and/or provide otherdesired properties. Tube 3250 may include an electrical stimulationelement to resist calcification and promote motility and satiety.Various electrical stimulation elements that can be utilized or modifiedfor use with the systems and methods disclosed herein are described, forexample, in U.S. Pat. No. 7,881,797 to Griffin et al., which is herebyincorporated by reference in its entirety. Tube 3250 may be made up ofone or more sections which may be coupled or uncoupled to adjust alength of tube 3250. Tube 3250 may include one, two, or more additionallumens interior to, exterior to, or within walls of tube 3250 fordelivery of medications, access for imaging devices for visualmonitoring, and access for diagnostic sampling. Tube 3250 may haveadditional lumens which open at different points along the length oftube 3250 for targeted delivery or access.

Tube 3250 may include a radiopaque marker 3254. Radiopaque marker 3254may be one or more longitudinal stripes which run along all or part ofthe length of tube 3250. Radiopaque marker 3254 may be configured tohelp prevent or reduce kinking and twisting of tube 3250. For example,radiopaque marker 3254 may be thicker and/or wider toward proximalportion 3251 of tube 3250 as shown in FIG. 3K, where kinking andtwisting may be more pronounced. Alternatively, radiopaque marker 3254may be a helical stripe as shown in FIG. 3L, circumferential bands, orother suitable configuration. Radiopaque marker 3254 may be coupled toan inside surface of tube 3250 to help maintain at least some patency oflumen 3253 and prevent lumen 3253 from closing completely when tube 3250is kinked or twisted. Alternatively, radiopaque marker 3254 may becoupled to an outside surface of tube 3250. Various embodiments,features, materials and parameters of cuffs, sleeves, anchors, and othercomponents that can be used or modified for use with those disclosedherein are described, for example, in the following patents andpublications, each of which are incorporated by reference in theirentireties: U.S. Pat. Pub. No. 2007/0198074 to Dann et al., U.S. Pat.No. 8,070,743 to Kagan et al., U.S. Pat. Pub. No. 2009/0149871 to Kaganet al., U.S. Pat. Pub. No. 2004/0092892 to Kagan et al., U.S. Pat. Pub.No. 2006/0155375 to Kagan et al., U.S. Pat. Pub. No. 2006/0015125 toSwain, U.S. Pat. Pub. No. 2006/0020254 to von Hoffmann, U.S. Pat. No.8,118,774 to Dann et al., U.S. Pat. Pub. No. 2009/0012553 to Swain etal., U.S. Pat. Pub. No. 2009/0012544 to Thompson et al., and U.S. Pat.Pub. No. 2009/0012541 to Dahl et al.

Tube 3250 may include one, two, three, or more tails 3255 at distalportion 3252. Tails 3255 may be folded over each other and cinched witha grasping element, such as a loop snare, to seal distal portion 3255 oftube 3250 during deployment of sleeve 3200. Tails 3255 may be asdescribed, for example, in U.S. Pat. No. 8,118,774 to Dann et al., whichis hereby incorporated by reference in its entirety.

Attachment elements 3260 are configured to be coupled to attachmentholes 3160. Attachment elements 3260 and attachment holes 3160 mayprovide a, first, e.g., a primary, or second, e.g., a backup couplingbetween sleeve 3200 and cuff 3100. Attachment elements 3260 andattachment holes 3160 may be configured to keep sleeve 3200 coupled tocuff 3100 if the coupling between retainer 3140 and ring 3240 shouldfail. Attachment elements 3260 may each include a suture 3261 and a bar3262. Bar 3262 may be configured to be threaded through attachment holes3160. Suture 3261 may be cut to release sleeve 3200 for removal orexchange.

One or more safety sutures may be used to provide a backup couplingbetween sleeve 3200 and cuff 3100. Safety sutures may be cut to releasesleeve 3200 for removal or exchange.

FIGS. 4A-4B show one embodiment of a tissue anchor 1300. FIG. 4A shows aperspective view of tissue anchor 1300. FIG. 4B shows a cross-sectionalview of tissue anchor 1300.

FIGS. 4C-4D show another embodiment of a tissue anchor 1300A. FIG. 4Cshows a perspective view of tissue anchor 1300A. FIG. 4D shows across-sectional view of tissue anchor 1300A.

The cuffs and/or sleeves described above may be anchored, for example,using tissue anchors 1300 and tissue anchors 1300A, or any othersuitable tissue anchor. Other tissue anchors or features of tissueanchors that may be used with systems and methods as described hereincan be found, for example, in U.S. Pat. Pub. No. 2009/0012541 to Dahl etal., which is hereby incorporated by reference in its entirety.

Tissue anchor 1300 and tissue anchor 1300A are configured to passthrough a tissue wall to retain a device. For example, tissue anchor1300 and tissue anchor 1300A may be configured to pass through an anchorhole in a cuff and transmurally through the wall of the esophagus toretain a cuff in the esophagus.

Tissue anchor 1300 and tissue anchor 1300A each include a proximalretention element 1310, a distal retention element 1320, and a tensionelement 1350.

Proximal retention element 1310 is configured to be deployed on aproximal side of a tissue wall. Proximal retention element 1310 may be abutton, a bar, or other suitable shape. In one embodiment, proximalretention element 1310 may be a button having a diameter ofapproximately 2 mm to 5 mm, and a thickness of approximately 0.25 mm to1 mm. Proximal retention element 1310 may include one or more holes1311.

Distal retention element 1320 is configured to be deployed on a distalside of a tissue wall. Distal retention element 1320 includes a hub 1330and a plurality of petals 1340.

Hub 1330 includes a proximal end 1331, a distal end 1332, and alongitudinal axis 1333. Hub 1330 includes an inner tube 1334 having acentral lumen 1335. Hub 1330 also includes an outer tube 1336. Innertube 1334 and outer tube 1336 form an annular space 1337. Inner tube1334 and outer tube 1336 may be substantially the same length, or be ofdifferent lengths. Inner tube 1334 and outer tube 1336 may be made of astainless steel or other suitable material.

Petals 1340 each include a hub portion 1341, an inclined portion 1342,and a tissue contact portion 1343. Hub portion 1341 is coupled to tissuecontact portion 1343 by inclined portion 1342. Hub portion 1341 is atleast partially positioned within annular space 1337. Hub portion 1341may be coupled to inner tube 1334 and outer tube 1336 with an adhesive1338. Adhesive 1338 may be a two-part epoxy or other suitable materialor adhesive. In one embodiment, hub portion 1341 may have a length ofapproximately 1 mm to 2 mm. Inclined portion 1342 extends from proximalend 1331 of hub 1330. In one embodiment, inclined portion 1342 may beinclined at an angle of approximately 30 to 60 degrees with respect tolongitudinal axis 1333. Alternatively, inclined portion 1342 may beinclined at a variable angle between 0 and 90 degrees with respect tolongitudinal axis 1333. In one embodiment as shown in FIGS. 4A-4B,inclined portion 1342 may have a length of approximately 3 mm to 4 mm.In another embodiment as shown in FIGS. 4C-4D, inclined portion 1342 mayhave a length of approximately 2 mm to 3 mm. Tissue contact portion 1343is configured to contact a distal surface of a tissue wall. Tissuecontact portion 1343 may be substantially flat, or it may be configuredto curve away from the distal surface of a tissue wall. Tissue contactportion 1343 may be substantially perpendicular to longitudinal axis1333 of hub 1330. Tissue contact portion 1343 may have an open structurewhich reduces the amount of material coming into contact with a distalsurface of a tissue wall. This open structure may reduce a response by atissue wall to tissue contact portion 1323. In one embodiment as shownin FIGS. 4A-4B, tissue contact portion 1343 may have a footprint havingan outside diameter of approximately 7 mm to 8 mm, and an insidediameter of approximately 4 mm to 5 mm. In another embodiment as shownin FIGS. 4C-4D, tissue contact portion 1343 may have a footprint havingan outside diameter of approximately 8 mm to 10 mm, and an insidediameter of approximately 4 mm to 5 mm. Petals 1340 may be sufficientlyflexible to be collapsed into a delivery configuration for deliveryinside a needle and expanded into a deployed configuration on a distalside of a tissue wall. Petals 1340 may be sufficiently flexible toprovide shock absorption. Petals 1340 may be formed of one or morelengths of wire, cut from one or more sheets of material, or made usingany other suitable method. In one embodiment, petals 1340 may be formedof wire having a diameter of approximately 0.1 mm to 0.2 mm. Petals 1340may be made of nitinol or other suitable material. Petals 1340 may becoated or treated with an antibiotic or other therapeutic agent.

Tension element 1350 includes a proximal portion 1351 and a distalportion 1352. Proximal portion 1351 is coupled to proximal retentionelement 1310. Proximal portion 1351 may pass through hole 1311 ofproximal retention element 1310 and coupled with one or more knots.Distal portion 1352 is positioned within central lumen 1335 of innertube 1334. Distal portion 1352 may be coupled to inner tube 1334 with anadhesive 1339 or other suitable ways. Adhesive 1339 may be a two-partepoxy or other suitable material or adhesive. Distal portion 1352 mayalso be coupled to inner tube 1334 with one or more knots. Tensionelement 1350 is configured to pass through a tissue wall. Tensionelement 1350 may have a reduced width or thickness in order to decreasethe size of the hole through a tissue wall, which may lower thelikelihood of infection or other response. In one embodiment, tensionelement 1350 may have a diameter of approximately 0.2 to 0.5 mm. Tensionelement 1350 may be elastic or inelastic. Tension element 1350 may be asuture, a wire, or other suitable device. Tension element 1350 may becoated or treated with an antibiotic agent.

FIGS. 5A-5C show one embodiment of a tissue marking device 1400. FIG. 5Ashows a perspective view of tissue marking device 1400. FIG. 5B shows anenlarged cross-sectional view of a distal portion of tissue markingdevice 1400. FIG. 5C shows an enlarged end view of a distal portiontissue marking device 1400.

Tissue marking device 1400 may be used for aiding the placement oftissue anchors, identifying cancerous tissue, marking tissue beforesurgery, and other purposes. In some embodiments, tissue marking device1400 may be used for purposes other than marking, such as for pinpointdelivery of a diagnostic or therapeutic agent into tissue, such as achemotherapeutic drug for example.

Tissue marking device 1400 may include a marking tube 1410, a markingtip 1420, a dye source 1444, and a vacuum source 1460.

Marking tube 1410 includes a proximal portion 1411 and a distal portion1412. Marking tube includes an inlet lumen 1413 and an outlet lumen1415. Marking tube 1410 is configured to access a part of the body wherethe tissue is located. Marking tube 1410 may be configured to be used ina working channel of an endoscope or other device.

Marking tip 1420 may be formed at distal portion 1412 of marking tube1410. Marking tip 1420 includes a passage 1421 formed in a wall 1414between inlet lumen 1413 and outlet lumen 1415. Marking tip 1420includes an opening 1426. Opening 1426 may be circular, cross-shaped,X-shaped, or any other suitable size and shape as desired for aparticular tissue identification, and in some embodiments could have afirst opening shape to mark a first tissue, and a second opening shapeto mark a second tissue. Opening 1426 may be chamfered on the insideand/or outside. Marking tip 1420 is configured to be placed against atissue to be marked. Marking tip 1420 may be any suitable size or shapedepending on the tissue to be marked. Opening 1426 could be on adistal-facing surface of marking tip 1420 as illustrated, or on asidewall of the marking tip 1420 in other embodiments, such as describedin connection with FIGS. 7A-7E below.

Dye source 1444 may be coupled to inlet lumen 1413. Dye source 1444 maybe a reservoir containing a dye for marking tissue. The dye may begentian violet or any other suitable ink or dye. Dye source 1444 may bea syringe or other device which allows the flow of the dye to becontrolled.

Optionally, a rinse source 1445 may be coupled to inlet lumen 1413.Rinse source 1445 may be a reservoir containing a rinse solution such assaline or water. Rinse source 1445 may be a syringe or other devicewhich allows the flow of the rinse solution to be controlled.

A single solution may be used which performs both functions of the dyeand the rinse solution.

A manifold 1450 may be used to couple dye source 1444 and rinse source1445 to inlet lumen 1413. Manifold 1450 may include one or more valves1451 which allow dye source 1444 and rinse source 1445 to be turned onand off independently.

Vacuum source 1460 may be coupled to outlet lumen 1415. Vacuum source1460 may be a pump or other suitable device. Vacuum source 1460 isconfigured to draw a tissue placed against marking tip 1420 and create aseal between opening 1426 and the tissue. Vacuum source 1460 is alsoconfigured to fill marking tip 1420 with a dye from dye source 1444 anda rinse solution from rinse source 1445.

Tissue marking device 1400 may be a sealed system, which allows for agiven fluid to be maintained in marking tip 1420 as long as a vacuum isapplied and a seal with the tissue is maintained.

FIGS. 6A-6D show one embodiment of a method for using tissue markingdevice 1400.

FIG. 6A shows positioning marking tip 1420 against a tissue to bemarked. An endoscope S may be used to place marking tip 1420 against thetissue.

FIG. 6B shows drawing the tissue against marking tip 1420. Vacuum source1460 is turned on to create a vacuum in marking tip 1420. Vacuum source1460 draws the tissue against marking tip 1420, creating a seal betweenopening 1426 and the tissue.

FIG. 6C shows marking the tissue. Valve 1451 for dye source 1444 isopened and vacuum source 1460 fills marking tip 1420 with a dye from dyesource 1444 to mark the tissue exposed through opening 1426. Vacuumsource 1460 may be used to maintain the dye in marking tip 1420 for alength of time to allow the dye to penetrate into the tissue. The dyemay then be evacuated from marking tip 1420.

Optionally, rinsing marking tip 1420 and/or the tissue may be performed.Valve 1451 for rinse source 1445 is opened and vacuum source 1460 fillsmarking tip 1420 with a rinse solution from rinse source 1445.

FIG. 6D shows marking tip 1420 removed from the tissue, showing thetissue mark.

FIG. 7A shows one embodiment of a tissue marking device 2400. FIGS.7B-7D show various embodiments of marking surface 2420. FIG. 7E showsvarious embodiments of openings 2426.

Tissue marking device 2400 may be used for aiding the placement oftissue anchors, identifying cancerous tissue, marking tissue beforesurgery, and other purposes. In some embodiments, tissue marking device2400 may be used for purposes other than marking, such as for pinpointdelivery of a diagnostic or therapeutic agent into tissue, such as achemotherapeutic drug for example.

Tissue marking device 2400 may include an access element 2410, a markinginterface 2420, a positioning element 2430, a dye source 2444, and avacuum source 2460.

Access element 2410 includes a proximal portion 2411 and a distalportion 2412. Access element 2410 may include an inlet tube 2413 and anoutlet tube 2415. Access element 2410 is configured to access a part ofthe body where the tissue is located. In one embodiment, an accesselement 2410 used for esophageal access may be a catheter of suitablelength and diameter to access the gastroesophageal junction or otherpart of the esophagus. Access element 2410 may be configured to be usedwith a visualization device. In other embodiments, access element 2410may be an endoscope, a solid elongate member, or other suitable deviceused to access the esophagus or other bodily cavities.

Marking surface 2420 may be coupled to distal portion 2412 of accesselement 2410. Alternatively, marking surface 2420 may be coupled to anysuitable part of access element 2410. Marking surface 2420 includes alumen 2421 having an inlet 2423 and an outlet 2425. Inlet 2423 andoutlet 2425 may be coupled to inlet tube 2413 and outlet tube 2415.Lumen 2421 may be linear, meandering, or U-shaped, as shown in FIGS.7B-7D, or any other suitable configuration. Lumen 2421 may include oneor more gaps 2422 for visualization. Marking surface 2420 includes oneor more openings 2426. Openings 2426 may be arranged in one or more rowsthat can be regularly or irregularly spaced apart. Regularly spacedapart rows may be advantageous, for example, for calibration ormeasuring of distances. Openings 2426 may be circular, cross-shaped,X-shaped, or any other suitable size and shape as desired for aparticular tissue identification, and in some embodiments could have afirst opening shape to mark a first tissue, and a second opening shapeto mark a second tissue. Openings 2426 may be chamfered on the insideand/or outside. Marking surface 2420 is configured to be placed againsta tissue to be marked. Marking surface 2420 may be any suitable size orshape depending on the tissue to be marked. In one embodiment, markingsurface 2420 may simply be a tube with one or more openings 2426 formedin a side of the tube.

Positioning element 2430 may be coupled to distal portion 2412 of accesselement 2410. Positioning element 2430 may be an expandable element,such as balloon, expandable mesh, or other suitable device. Positioningelement 2430 may be coupled a known distance proximal or distal tomarking surface 2420. Positioning element 2430 may be used to positionmarking surface 2420 with respect to an anatomical feature. In oneembodiment, positioning element 2430 is a balloon configured to beexpanded in the stomach, and configured to position marking surface 2420in the esophagus a known distance from the opening of the stomach.

Optionally, a first rinse source 2441 may be coupled to inlet tube 2413.First rinse source 2441 may be a reservoir containing a first rinsesolution such as saline or water. First rinse source 2441 may be asyringe or other device which allows the flow of the first rinsesolution to be controlled.

Optionally, a second rinse source 2442 may be coupled to inlet tube2413. Second rinse source 2442 may be a reservoir containing a secondrinse solution such as acetic acid. Second rinse source 2442 may be asyringe or other device which allows the flow of the second rinsesolution to be controlled.

Optionally, a prep source 2443 may be coupled to inlet tube 2413. Prepsource 2443 may be a reservoir containing a prep solution such asisopropyl alcohol. Prep source 2443 may be a syringe or other devicewhich allows the flow of the prep solution to be controlled.

Dye source 2444 may be coupled to inlet tube 2413. Dye source 2444 maybe a reservoir containing a dye for marking tissue. The dye may begentian violet or any other suitable ink or dye. Dye source 2444 may bea syringe or other device which allows the flow of the dye to becontrolled.

Optionally, a third rinse source 2445 may be coupled to inlet tube 2413.Third rinse source 2445 may be a reservoir containing a third rinsesolution such as saline or water. Third rinse source 2445 may be asyringe or other device which allows the flow of the third rinsesolution to be controlled.

A single solution may be used which performs two or more functions ofthe first rinse solution, second rinse solution, prep solution, dye, andthird rinse solution.

A manifold 2450 may be used to couple first rinse source 2441, secondrinse source 2442, prep source 2443, dye source 2444, and third rinsesource 2445 to inlet tube 2413. Manifold 2450 may include one or morevalves 2451 which allow first rinse source 2441, second rinse source2442, prep source 2443, dye source 2444, and third rinse source 2445 tobe turned on and off independently.

Vacuum source 2460 is coupled to outlet tube 2415. Vacuum source 2460may be a pump or other suitable device. Vacuum source 2460 is configuredto create a vacuum within lumen 2421 of marking surface 2420. Vacuumsource 2460 is configured to draw a tissue placed against markingsurface 2420 and create a seal between openings 2426 and the tissue.Vacuum source 2460 is configured to fill lumen 2421 with a first rinsesolution from first rinse source 2441, a second rinse solution fromsecond rinse source 2442, a prep solution from prep source 2443, a dyefrom dye source 2444, and/or a third rinse solution from third rinsesource 2445.

Tissue marking device 2400 may be a sealed system, which allows for agiven fluid to be maintained in lumen 2421 as long as a vacuum isapplied and a seal with the tissue is maintained.

FIGS. 8A-8F show one embodiment of a method for using tissue markingdevice 2400.

FIG. 8A shows introducing access element 2410 into a first location,e.g., the esophagus and introducing positioning element 2430 into asecond location, e.g., the stomach which in some embodiments may bedistal to the first location.

FIG. 8B shows expanding positioning element 2430 in the stomach.

FIG. 8C shows seating positioning element 2430 against the opening ofthe stomach to position marking surface 2420 a known distance from theopening of the stomach in the esophagus. Alternatively, marking surface2420 may be positioned using an initial mark made previously by tissuemarking device 1400.

FIG. 8D shows drawing the tissue against marking surface 2420. Vacuumsource 2460 is turned on to create a vacuum in lumen 2421. Vacuum source2460 draws the tissue against marking surface 2420, creating a sealbetween openings 2426 and the tissue.

Optionally, rinsing the tissue may be performed one or more times. Valve2451 for first rinse source 2441 is opened and vacuum source 2460 fillslumen 2421 with a first rinse solution from first rinse source 2441 torinse the tissue exposed through openings 2426. Valve 2451 for secondrinse source 2442 is opened and vacuum source 2460 fills lumen 2421 witha second rinse solution from second rinse source 2442 to rinse thetissue exposed through openings 2426.

Optionally, preparing the tissue may be performed. Valve 2451 for prepsource 2443 is opened and vacuum source 2460 fills lumen 2421 with aprep solution from prep source 2443 to prepare the tissue exposedthrough openings 2426.

FIG. 8E shows marking the tissue. Valve 2451 for dye source 2444 isopened and vacuum source 2460 fills lumen 2421 with a dye from dyesource 2444 to mark the tissue exposed through openings 2426. Vacuumsource 2460 may be used to maintain the dye in lumen 2421 for a lengthof time to allow the dye to penetrate into the tissue. The dye is thenevacuated from lumen 2421.

Optionally, rinsing lumen 2421 and/or the tissue may be performed. Valve2451 for third rinse source 2445 is opened and vacuum source 2460 fillslumen 2421 with a third rinse solution from third rinse source 2445 torinse lumen 2421 and/or the tissue exposed through openings 2426.

FIG. 8F shows marking surface 2420 removed from the tissue, showing thetissue marks.

FIGS. 9A-9C show one embodiment of a sleeve delivery device 1500. FIG.9A shows a perspective view of sleeve delivery device 1500. FIG. 9Bshows an enlarged view of a distal portion of sleeve delivery device1500. FIG. 9C shows a cross-sectional view of sleeve delivery device1500.

Sleeve delivery device 1500 may be used to deliver a gastrointestinalsleeve. Sleeve delivery device 1500 may also be used to deliver agastrointestinal cuff together with or apart from a gastrointestinalsleeve.

Sleeve delivery device 1500 may include a handle 1510, a deliverycatheter 1520, a sealing element 1540, a release element 1550, and apump 1570.

Handle 1510 may include a sealing port 1514, a release port 1515, a pumpport 1517, and a snare port 1518. Snare port 1518 is configured toreceive a loop snare or other grasping device.

Delivery catheter 1520 includes a proximal portion 1521 and a distalportion 1522. Proximal portion 1521 is coupled to handle 1510. Distalportion 1522 is configured to receive a proximal portion of agastrointestinal sleeve. Distal portion 1522 may be curved to facilitateplacement into the pylorus and/or intestine. Delivery catheter 1520includes a delivery lumen 1523, a sealing lumen 1524, and a releaselumen 1525. Delivery lumen 1523 is configured to receive at least adistal portion of a gastrointestinal sleeve which may be inverted insidedelivery lumen 1523. Sealing lumen 1524 is in communication with asealing opening 1534 formed in a side of distal portion 1522. Releaselumen 1525 is in communication with a release opening 1535 formed in aside of distal portion 1522.

Sealing element 1540 is configured to form a substantially fluid-tightseal between a proximal portion of a sleeve, such as a gastrointestinalsleeve, and distal portion 1522 of delivery catheter 1520, when aproximal portion of a gastrointestinal sleeve is placed over distalportion 1522 of delivery catheter 1520. Sealing element 1540 is alsoconfigured to retain a gastrointestinal sleeve to delivery catheter 1520during delivery. Sealing element 1540 may be, for example, a suture,wire, or other means that runs through sealing lumen 1524, exits out ofsealing opening 1534, and wraps one or more times around a proximalportion of a gastrointestinal sleeve placed over distal portion 1522 ofdelivery catheter 1520. Sealing element 1540 may include a distalportion 1542 having a loop or a ring.

Release element 1550 is slidably disposed in release lumen 1525. Releaseelement 1550 is configured to retain a distal portion 1542 of sealingelement 1540. Release element 1550 is exposed at release opening 1535.Release element 1550 may be a wire. Alternatively, release element 1550may be a suture or other suitable device.

Pump 1570 is configured to be coupled to pump port 1517. Pump 1570 isconfigured to pump a fluid such as water into delivery lumen 1523 toevert a gastrointestinal sleeve loaded onto delivery catheter 1520. Pump1570 may include controls for pressure, volume, flow rate, time, orother parameters.

FIGS. 9D-9G show one embodiment of a method for loading sleeve deliverydevice 1500. FIG. 9D shows placing a proximal portion of agastrointestinal sleeve over distal portion 1522 of delivery catheter1520. FIG. 9E shows wrapping sealing element 1540 around the proximalportion of the gastrointestinal sleeve. FIG. 9F shows securing distalportion 1542 of sealing element 1540 in release opening 1535 usingrelease element 1550. FIG. 9G shows tightening of sealing element 1540around the proximal portion of the gastrointestinal sleeve. The loadingmay be completed by inserting a grasper, such as a loop snare throughdelivery lumen 1523 and the gastrointestinal sleeve, sealing a distalportion of the gastrointestinal sleeve, and using the loop snare to pullthe distal portion of the gastrointestinal sleeve into delivery lumen1523 to invert the gastrointestinal sleeve into delivery lumen 1523.Further examples of everting systems and methods that can be used withthe systems and methods disclosed herein can be found, for example, inU.S. Pat. No. 8,118,774 and U.S. Pat. Pub. No. 2007/0198074, both ofwhich are incorporated by reference in their entireties.

FIGS. 10A-10C show another embodiment of a sleeve delivery device 2500.FIG. 10A shows a perspective view of sleeve delivery device 2500. FIG.10B shows an enlarged view of a distal portion of sleeve delivery device2500. FIG. 10C shows a cross-sectional view of sleeve delivery device2500.

Sleeve delivery device 2500 may be used to deliver a gastrointestinalsleeve. Sleeve delivery device 2500 may also be used to deliver agastrointestinal cuff together with or apart from a gastrointestinalsleeve.

Sleeve delivery device 2500 may include a handle 2510, a deliverycatheter 2520, a sealing element 2540, one or more rings 2550, and apump 2570.

Handle 2510 may include a sealing port 2514, a pump port 1517, and asnare port 2518. Snare port 2518 is configured to receive a loop snareor other grasping device.

Delivery catheter 2520 includes a proximal portion 2521 and a distalportion 2522. Proximal portion 2521 is coupled to handle 2510. Distalportion 2522 is configured to receive a proximal portion of agastrointestinal sleeve. Distal portion 2522 may be curved to facilitateplacement into the pylorus and/or intestine. Delivery catheter 2520includes a delivery lumen 2523 and a sealing lumen 2524. Delivery lumen2523 is configured to receive at least a distal portion of agastrointestinal sleeve which may be inverted inside delivery lumen2523. Sealing lumen 2524 is in communication with a sealing opening 2534formed in a side of distal portion 2522.

Sealing element 2540 is configured to form a substantially fluid-tightseal between a proximal portion of a sleeve, such as a gastrointestinalsleeve, and distal portion 2522 of delivery catheter 2520, when aproximal portion of a gastrointestinal sleeve is placed over distalportion 2522 of delivery catheter 2520. Sealing element 2540 is alsoconfigured to retain a gastrointestinal sleeve to delivery catheter 2520during delivery. Sealing element 2540 may be, for example, a suture,wire, or other means that runs through sealing lumen 2524, exits out ofsealing opening 2534, and wraps one or more times around a proximalportion of a gastrointestinal sleeve placed over distal portion 1522 ofdelivery catheter 1520. Sealing element 1540 may include a distalportion 1542 that may be tied to sealing element 1540 with a releasableknot.

Rings 2550, which may include any radially outwardly protrudingstructure, may be formed or coupled around distal portion 2522 ofdelivery catheter 2520. Rings 2550 may be coupled with heat shrinktubing, an adhesive, or other suitable methods. Rings 2550 areconfigured to fit inside a proximal portion of a gastrointestinalsleeve. Rings 2550 may cooperate with sealing element 2540 to help sealand retain a proximal portion of a gastrointestinal sleeve around distalportion 2522 of delivery catheter 2520.

Pump 2570 is configured to be coupled to pump port 2517. Pump 2570 isconfigured to pump a fluid such as water into delivery lumen 2523 toevert a gastrointestinal sleeve loaded onto delivery catheter 2520. Pump2570 may include controls for pressure, volume, flow rate, time, orother parameters.

FIGS. 10D-10G show one embodiment of a method for loading sleevedelivery device 2500. FIG. 10D shows placing a proximal portion of agastrointestinal sleeve over distal portion 2522 of delivery catheter2520 and over rings 2550. FIG. 10E shows wrapping sealing element 2540around the proximal portion of the gastrointestinal sleeve between tworings 2550. FIG. 10F shows securing sealing element 2540 to itself bytying a knot that will release when pulled, such as a slip knot. FIG.10G shows tightening of sealing element 2540 around the proximal portionof the gastrointestinal sleeve. The loading may be completed byinserting a grasper, such as a loop snare, through delivery lumen 2523and the gastrointestinal sleeve, sealing a distal portion of thegastrointestinal sleeve, and using the loop snare to pull the distalportion of the gastrointestinal sleeve into delivery lumen 2523 toinvert the gastrointestinal sleeve into delivery lumen 2523. Furtherexamples of everting systems and methods that can be used with thesystems and methods disclosed herein can be found, for example, in U.S.Pat. No. 8,118,774 and U.S. Pat. Pub. No. 2007/0198074, both of whichare incorporated by reference in their entireties.

FIGS. 11A-11C show yet another embodiment of a sleeve delivery device3500. FIG. 11A shows a perspective view of sleeve delivery device 3500.FIG. 11B shows an enlarged view of a distal portion of sleeve deliverydevice 3500. FIG. 11C shows a cross-sectional view of sleeve deliverydevice 3500.

Sleeve delivery device 3500 may be used to deliver a gastrointestinalsleeve. Sleeve delivery device 3500 may also be used to deliver agastrointestinal cuff together with or apart from a gastrointestinalsleeve.

Sleeve delivery device 3500 may include a handle 3510, a deliverycatheter 3520, a balloon 3540, a boot 3560, and a pump 3570.

Handle 3510 may include an inflation port 3514, a boot release port3516, a pump port 3517, and a snare port 3518. Inflation port 3514 isconfigured to be coupled to an inflation source. Snare port 3518 isconfigured to receive a loop snare or other grasping device.

Delivery catheter 3520 includes a proximal portion 3521 and a distalportion 3522. Proximal portion 3521 is coupled to handle 3510. Distalportion 3522 is configured to receive a proximal portion of agastrointestinal sleeve. Distal portion 3522 may be curved to facilitateplacement into the pylorus and/or intestine. Delivery catheter 3520includes a delivery lumen 3523, an inflation lumen 3524, and a bootrelease lumen 3526. Delivery lumen 3523 is configured to receive atleast a distal portion of a gastrointestinal sleeve which may beinverted inside delivery lumen 3523. Inflation lumen 3524 is incommunication with balloon 3540. Boot release lumen 3526 is incommunication with a boot release opening 3536 formed in a side ofdistal portion 3522.

Balloon 3540 is coupled to distal portion 3522 of delivery catheter3520. Balloon 3540 is configured to form a substantially fluid-tightseal between a proximal portion of a sleeve, such as a gastrointestinalsleeve, and distal portion 3522 of delivery catheter 3520, when aproximal portion of a gastrointestinal sleeve is placed over distalportion 3522 of delivery catheter 3520. Balloon 3540 is also configuredto retain a gastrointestinal sleeve to delivery catheter 3520 duringdelivery. Balloon 3540 may be a circumferential balloon coupled arounddistal portion 3522 of delivery catheter 3520.

Boot 3560 is configured to wrap around a proximal portion of agastrointestinal sleeve placed over distal portion 3522 of deliverycatheter 3520. Boot 3560 is configured to prevent damage to or snaggingof a proximal portion of a gastrointestinal sleeve during delivery. Boot3560 has an outside profile configured to minimize trauma and damage toesophagus and other tissue during delivery. Boot 3560 may also help toretain a gastrointestinal sleeve to delivery catheter 3520. Boot 3560includes a boot release 3561. Boot release 3561 may be, for example, asuture, wire, or other means that runs through boot release lumen 3526,exits out of boot release opening 3536, and attaches to boot 3560. Bootrelease 3561 is configured to unzip, tear open, cut, degrade, orotherwise disassociate boot 3560 to release it from delivery catheter3520. Boot 3560 may include perforations 3562 and a tongue 3563 tofacilitate release. Boot 3560 may be made of plastic, fabric, or othersuitable material. When sleeve delivery device 3500 is used to deliver agastrointestinal cuff together with a gastrointestinal sleeve, boot 3560may be long enough to wrap around both the gastrointestinal cuff and theproximal portion of the gastrointestinal sleeve. A boot 3560 may also beused with sleeve delivery devices 1500 and 2500.

Pump 3570 is configured to be coupled to pump port 3517. Pump 3570 isconfigured to pump a fluid such as water into delivery lumen 3523 toevert a gastrointestinal sleeve loaded onto delivery catheter 3520. Pump3570 may include controls for pressure, volume, flow rate, time, orother parameters.

FIGS. 11D-11G show one embodiment of a method for loading sleevedelivery device 3500. FIG. 11D shows placing a proximal portion of agastrointestinal sleeve over distal portion 3522 of delivery catheter3520 and over balloon 3540. FIG. 11E shows folding the proximal portionof the gastrointestinal sleeve around distal portion 3522 of deliverycatheter 3520. The loading may be continued by inserting a grasper, suchas a loop snare, through delivery lumen 3523 and the gastrointestinalsleeve, sealing a distal portion of the gastrointestinal sleeve, andusing the loop snare to pull the distal portion of the gastrointestinalsleeve into delivery lumen 3523 to invert the gastrointestinal sleeveinto delivery lumen 3523. FIG. 11F shows wrapping boot 3560 around thenow folded proximal portion of the gastrointestinal sleeve and attachingboot 3560 to boot release 3561. FIG. 11G shows inflating balloon 3540.Further examples of everting systems and methods that can be used withthe systems and methods disclosed herein can be found, for example, inU.S. Pat. No. 8,118,774 and U.S. Pat. Pub. No. 2007/0198074, both ofwhich are incorporated by reference in their entireties.

FIGS. 12A-12C show one embodiment of an anchor delivery device 1600.FIG. 12A shows a perspective view of anchor delivery device 1600. FIG.12B shows an exploded view of anchor delivery device 1600. FIG. 12Cshows an enlarged cross-sectional view of a distal portion of anchordelivery device 1600 with a tissue anchor loaded.

Anchor delivery device 1600 includes a handle 1610, a sheath 1650, adelivery needle 1660, and a stylet 1670.

Handle 1610 includes a needle control 1616 and a stylet control 1617.

Sheath 1650 includes a proximal portion 1651, a distal portion 1652, anda sheath lumen 1655. Proximal portion 1651 of sheath 1650 may be coupledto handle 1610. Sheath 1650 is configured to be slidably disposed in aworking lumen of an endoscope.

Delivery needle 1660 is slidably disposed in sheath lumen 1655. Deliveryneedle 1660 includes a proximal portion 1661, a distal portion 1662, anda needle lumen 1665. Proximal portion 1661 may be coupled to needlecontrol 1616. Distal portion 1662 may include a tip 1668 that is sharp.Alternatively, tip 1668 may be atraumatic and coupled to an RF or otherenergy source. Distal portion 1662 may be advanced out of and refractedinto sheath 1620. Distal portion 1662 may be preformed with a curve, ormade of a shape memory material. This curve may be straightened out whendistal portion 1662 is retracted into sheath 1620. Distal portion 1662may be made of the same material as the rest of delivery needle 1660.Alternatively, distal portion 1662 may be made of a different materialfor greater curve and/or flexibility. For example, distal portion 1662may be made of a polyamide and the rest of delivery needle 1660 may bemade of nitinol. Delivery needle 1660 is configured to receive a tissueanchor collapsed into a delivery configuration.

Stylet 1670 is slidably disposed in needle lumen 1665. Stylet 1670includes a proximal portion 1671 and a distal portion 1672. Proximalportion 1671 may be coupled to stylet control 1617. Distal portion 1672may be advanced out of and retracted into delivery needle 1660. Stylet1670 is configured to push out a tissue anchor loaded in delivery needle1660.

FIGS. 13A-13E show one embodiment of a method for using anchor deliverydevice 1600. Other systems and methods that can be used or modified foruse with anchor delivery devices as described herein can be found, forexample, in U.S. Pat. Pub. No. 2009/0012541 to Dahl et al., which ishereby incorporated by reference in its entirety.

FIG. 13A shows loading anchor delivery device 1600 with a tissue anchor,e.g., tissue anchor 1300. Delivery needle 1660 is retracted insidesheath 1650. A distal retention element of a tissue anchor is loadedinto delivery needle 1660. A proximal retention element of tissue anchor1300 hangs outside of delivery needle 1660. A therapeutic agent, e.g.,an antibiotic gel, may also be loaded into delivery needle 1660.

FIG. 13B shows advancing delivery needle 1660 through sheath 1650 andtransmurally through a tissue wall W. The proximal retention element ismaintained on a proximal side of the tissue wall W, e.g., on a mucosalsurface. In other embodiments tissue anchor 1300 may be placed through aplication.

FIG. 13C shows advancing stylet 1640 through delivery needle 1630 todeploy the distal retention element on a distal side of the tissue wallW, e.g., on a serosal surface. The antibiotic gel may also be pushedout.

FIG. 13D shows positioning and/or turning over tissue anchor 1300 asnecessary using laparoscopic instruments positioned on the distal sideof the tissue wall W.

FIG. 13E shows retracting delivery needle 1660 back through the tissuewall and back into sheath 1650, leaving a tension element of tissueanchor 1300 in place through the tissue wall W.

FIGS. 14A-14C show one embodiment of a stent 1690. FIG. 14A shows a topview of stent 1690. FIG. 14B shows stent 1690 in an collapsedconfiguration coupled to a gastrointestinal cuff. FIG. 14C shows stent1690 in an expanded configuration coupled to a gastrointestinal cuff.

Stent 1690 may be removably coupled to a gastrointestinal cuff to createa working space inside the esophagus. Stent 1690 may also be usedwithout being coupled to the gastrointestinal cuff. Stent 1690 may beused in conjunction with anchor delivery device 1600.

Stent 1690 includes a plurality of proximal segments 1691 and aplurality of distal segments 1692 connected by connecting segments 1693.Proximal segments 1691 may include proximal drawstring holes 1694. Aproximal drawstring 1695 may be threaded through proximal drawstringholes 1692. A proximal drawstring control 1696 may be coupled toproximal drawstring 1695. Proximal drawstring control 1696 is configuredto loosen and tighten proximal drawstring 1695 to expand and collapse aproximal portion of stent 1690. Distal segments 1692 may include distaldrawstring holes 1697. A distal drawstring 1698 may be threaded throughdistal drawstring holes 1697. A distal drawstring control 1699 may becoupled to distal drawstring 1698. Distal drawstring control 1699 isconfigured to loosen and tighten distal drawstring to expand andcollapse a distal portion of stent 1690.

Stent 1690 may be removably coupled to an inner surface of a proximalportion of a gastrointestinal cuff. Stent 1690 may be sutured to thegastrointestinal cuff. Stent 1690 may be delivered in a collapsedconfiguration together with the gastrointestinal cuff, and expanded atan attachment point to create a working space. When the working space isno longer needed, the sutures may be cut and removed, and stent 1690collapsed and removed.

Stent 1690 may also be used without being coupled to a gastrointestinalcuff. Stent 1690 may be delivered in a collapsed configuration into apreviously placed gastrointestinal cuff, and expanded to create aworking space. When the working space is no longer needed, the stent1690 may be collapsed and removed.

FIGS. 15A-15G show another embodiment of an anchor delivery device 2600.FIG. 15A shows a perspective view of anchor delivery device 2600. FIG.15B shows an exploded view of anchor delivery device 2600. FIG. 15Cshows a side cross-sectional view of a distal portion of anchor deliverydevice 2600. FIG. 15D shows a side cross-sectional view of a distalportion of sled 2650. FIG. 15E shows a side view of a delivery needle2660, a pushrod 2670, and a holder 2680. FIG. 15F shows an enlarged viewof a delivery needle 2660 and a pushrod 2670. FIG. 15G shows an endcross-sectional view of a distal portion of anchor delivery device 2600.

Anchor delivery device 2600 includes a handle 2610, a catheter 2620, aside port 2630, a sled 2650, a delivery needle 2660, pushrod 2670, and aholder 2680.

Handle 2610 includes a needle control 2616, a pushrod control 2617, anda holder control 2618.

Catheter 2620 includes a proximal portion 2621, a distal portion 2622,and a longitudinal axis 2623. Catheter 2620 also includes a centrallumen 2625. Distal portion 2622 may include a nose 2626 having anopening 2627. Nose 2626 may be soft and flexible. Nose 2626 may beelongate. Nose 2626 may be curved. Opening 2627 may be configured toallow an endoscope or other tool to pass through. Distal portion 2622may also include an alignment slot 2628 and a stop 2629.

Side port 2630 is formed in a side of distal portion 2622 of catheter2620. Side port 2630 includes a proximal side 2631 and a distal side2632. Side port 2630 may optionally include a tissue brace 2634 slidablydisposed within a brace lumen of catheter 2620. Tissue brace 2634 may beconfigured to removably cover side port 2630 to prevent tissue fromprematurely entering side port 2630. Side port 2630 may be coupled to avacuum source. Side port 2630 may be configured to be placed against anddraw in a tissue wall. Side port 2630 may be sized larger to allowenough of a tissue wall to be drawn in for single-wall (transmural)anchor delivery, or sized smaller for double-wall (plication) anchordelivery. For single-wall anchor delivery, side port 2630 may have alength of 10 mm to 50 mm or greater, such as a length of 20 mm to 30 mm.

Sled 2650 is slidably disposed in central lumen 2625. Sled 2650 includesa sheathing channel 2655 having a proximal opening 2656. Sled 2650 maybe coupled to a sled control rod 2657 configured to move sled 2650. Sledcontrol rod 2657 may be coupled to handle 2610. Sled 2650 may include analignment tab 2658 which cooperates with alignment slot 2628 to alignproximal opening 2656 with side port 2630. Sled 2650 may be configuredto slide in central lumen 2625 distally until it reaches stop 2629. Whensled 2650 has reached stop 2629, proximal opening 2656 of sheathingchannel 2655 may be positioned at distal side 2632 of side port 2630.Sled 2650 may be removed from catheter 2620 for reloading.

Delivery needle 2660 is slidably disposed in sheathing channel 2655.Delivery needle 2660 includes a distal control portion 2661, a proximaldelivery portion 2662, and a needle lumen 2665. Distal control portion2661 may be coupled to a needle control rod 2667. Needle control rod2667 may be coupled to needle control 2616. Proximal delivery portion2662 includes a tip 2668 that is sharp. Alternatively, tip 2668 may beatraumatic and coupled to an RF or other energy source. Delivery needle2660 has a reverse orientation, with tip 2668 pointed proximally (e.g.,toward the oropharynx, when the device 2600 is deployedtransesophageally via an endoscopic technique) and movable from a first,e.g., distal retracted position to a second, e.g., proximal position fordelivering a tissue anchor across a body luminal wall. Proximal deliveryportion 2662 may be advanced out of and retracted into sheathing channel2655. When advanced out of sheathing channel 2655, proximal deliveryportion 2662 may enter distal side 2632 of side port 2630. Deliveryneedle 2660 is configured to receive a tissue anchor collapsed into adelivery configuration. Delivery needle 2660 may include a slot 2669configured to allow a tension element of a tissue anchor to passthrough.

Pushrod 2670 is slidably disposed in needle lumen 2664. Pushrod 2670includes a distal control portion 2671 and a proximal delivery portion2672. Distal control portion 2671 may be coupled to a pushrod controlrod 2677. Pushrod control rod 2677 may be coupled to pushrod control2617. Pushrod 2670 has a reverse orientation, with proximal deliveryportion 2672 pointed proximally. Proximal delivery portion 2672 may beadvanced out of and retracted into delivery needle 2660. Pushrod 2670 isconfigured to push out a tissue anchor loaded in delivery needle 2660.Pushrod 2670 may include at least a portion, e.g., proximal deliveryportion 2672, sized small enough to push against a hub of a tissueanchor without damaging the tissue anchor or a portion thereof, e.g.,the petals. Pushrod 2670 may include a channel 2679 configured to allowa tension element of a tissue anchor to pass through. Channel 2679 ofpushrod 2670 may be aligned with slot 2669 of delivery needle 2660.

Holder 2680 may be coupled to a holder control rod 2687. Holder controlrod 2687 may be coupled to holder control 2618. Holder 2680 may beconfigured to hold an anchor hole of a gastrointestinal cuff overproximal opening 2656 of sheathing channel 2655. Holder 2680 may beconfigured to hold an anchor hole of a gastrointestinal cuff over tip2668 of delivery needle 2660. Holder 2680 may be slidably and/orrotatably manipulated. Holder 2680 may be stowed when not in use.

The control rods may be arranged coaxially. For example, sled controlrod 2657 may be slidably disposed in a hollow pushrod control rod 2677,which is slidably disposed in a hollow needle control rod 2667, which isslidably disposed in a hollow holder control rod 2687, as shown in FIG.15G. As another example, pushrod control rod 2677 may be slidablydisposed in a hollow needle control rod 2667, which is slidably disposedin a hollow sled control rod 2657, which is slidably disposed in ahollow holder control rod 2687. Alternatively, the control rods may bearranged non-coaxially, such as in a multi-lumen carrier tube. In someembodiments, anchor delivery device 2600 may also include an integratedvacuum port operably connected to a source of vacuum. In someembodiments, the vacuum may be delivered via a port on a separateendoscope or other device.

FIGS. 16A-16F show one embodiment of a method for using anchor deliverydevice 2600. Sheathing lumen 2655 is represented by the cross-hatchedarea. For clarity, only delivery needle 2660 and pushrod 2670 are shown.

FIG. 16A shows loading delivery needle 2660. Sled 2650 is removed fromcatheter 2620. Pushrod 2670 is taken out of delivery needle 2660. Anantibiotic gel may be loaded into delivery needle 2660. A distalretention element of a tissue anchor, e.g., tissue anchor 1300, isloaded through distal control portion 2661. A tension element of tissueanchor 1300 is passed through slot 2669 and channel 2679. A proximalretention element is positioned outside of delivery needle 2660.

FIG. 16B shows loading catheter 2620. Pushrod 2670 is inserted intodelivery needle 2660. The distal retention element is positioned insidetip 2668. Sled 2650 is inserted into catheter 2620 and seated in distalportion 2622. Proximal opening 2656 of sheathing channel 2655 ispositioned at distal side 2632 of side port 2630.

FIG. 16C shows capturing the gastrointestinal cuff. Holder 2680 may beused to hold an anchor hole of the gastrointestinal cuff over proximalopening 2656 of sheathing channel 2655. Delivery needle 2660 may beadvanced a small amount so that tip 2668 threads through the anchorhole. A tissue wall W is drawn in through side port 2630 using a vacuumsource. The tissue wall W at proximal side 2631 of side port 2630 may beat least partially drawn up into central lumen 2625 of catheter 2620.Tissue marks made previously, such as those made by tissue markingdevice 1400 and/or tissue marking device 2400, may be used to positiondelivery needle 2660.

FIG. 16D shows advancing delivery needle 2660. Delivery needle 2660 isadvanced through the tissue wall W at distal side 2632 of side port2630. Pushrod 2670 is also advanced, but is not moved relative todelivery needle 2660. Handle 2610 and needle control 2616 may beconfigured to preset the distance delivery needle 2660 is advanced toreduce the risk of penetrating the tissue wall W through proximal side2631 of side port 2630.

FIG. 16E shows retracting the delivery needle 2660. Delivery needle 2660is retracted while keeping pushrod 2670 in place to deploy the distalretention element. The antibiotic gel may also be released.

FIG. 16F shows stowing delivery needle 2660 and pushrod 2670. Deliveryneedle 2660 and pushrod 2670 are retracted into sheathing channel 2655.Anchor delivery device 2600 includes a delivery needle 2660 with areverse throw, which makes it convenient for use with anchor holes on aproximal portion of a gastrointestinal cuff. The reverse throw avoidsthe need to draw more of the gastrointestinal cuff into side port 2630.This and other anchor delivery systems and methods used herein can beused to accurately deliver one or a plurality of tissue anchors througha single transmural wall or to create or reinforce one or a plurality oftissue plications. Furthermore, anchor delivery system 2600 mayadvantageously reduce the risk of puncturing other body structures inclose proximity, e.g., the aorta. In some embodiments, anchor deliverysystems as described herein can be used via a pure endoscopic approach,e.g., as illustrated in connection with FIGS. 18A-18J below, withoutnecessarily requiring laparoscopic assistance.

FIGS. 17A-17H show one embodiment of a method for implanting agastrointestinal bypass device 1000. The method may also be used withgastrointestinal bypass device 2000 and gastrointestinal bypass device3000.

Sleeve delivery device 1500 is mounted with cuff 1100 and sleeve 1200.Sleeve delivery device 2500 or sleeve delivery device 3500 may also beused. Stent 1690 is coupled to cuff 1100. Stent 1690 is cinched aroundsleeve delivery device 1500.

FIG. 17A shows introducing sleeve delivery device 1500. Sleeve deliverydevice 1500 may position sleeve 1200 at or near the pylorus. Sleevedelivery device 1500 may be introduced with or without an overtube. Anendoscope may be used for guidance and visualization.

FIG. 17B shows deploying sleeve 1200. A fluid is pumped into deliverydevice 1500 to evert sleeve 1200 past the pylorus and into theintestine.

FIG. 17C shows positioning cuff 1100 and sleeve 1200 at the attachmentpoint. Sleeve delivery device 1500 pulls cuff 1100 and sleeve 1200proximally up to the gastroesophageal junction or other attachmentpoints, some of which are described elsewhere in the application.

FIG. 17D shows releasing cuff 1100 and sleeve 1200 from sleeve deliverydevice 1500. Sleeve delivery device 1500 is then withdrawn.

FIG. 17E shows introducing a laparoscopic tool L. Laparoscopic tool L ispositioned on a distal side of the attachment point. Laparoscopic tool Lmay be used to clear tissue around the esophagus to create a workingspace.

FIG. 17F shows introducing anchor delivery device 1600. Anchor deliverydevice 1600 may be used in the working lumen of an endoscope. Anchordelivery device 1600 may be introduced with or without an overtube.Anchor delivery device 1600 is positioned on a proximal side of theattachment point. Stent 1690 is opened to create a working space.

FIG. 17G shows delivering tissue anchors 1300. Anchor delivery device1600 is delivers tissue anchors 1300 through cuff 1100 and the wall ofthe esophagus. Any suitable tissue anchor may also be used. Tissue marksmade earlier by tissue marking device 1400 may be used as a guide.Laparoscopic tool L may be held against the distal side of theattachment point to reduce tenting. Laparoscopic tool L may be used toflip over distal retention element 1320 of tissue anchor 1300.

FIG. 17H shows removing stent 1690 from cuff 1100. The sutures used tocouple stent 1690 to cuff 1100 may be cut and removed. Stent 1690 may becinched using proximal drawstring 1695 and/or distal drawstring 1698 andremoved. Stent 1690 may be removed with or without an overtube.

FIGS. 18A-18J show yet another embodiment of a method for implanting agastrointestinal bypass device 3000. The method may also be used withgastrointestinal bypass device 1000 and gastrointestinal bypass device2000.

Sleeve delivery device 1500 is mounted with cuff 3100 and sleeve 3200.Sleeve delivery device 2500 or sleeve delivery device 3500 may also beused.

FIG. 18A shows introducing sleeve delivery device 1500. Sleeve deliverydevice 1500 may position sleeve 3200 at or near the pylorus. Sleevedelivery device 1500 may be introduced with or without an overtube. Anendoscope may be used for guidance and visualization.

FIG. 18B shows deploying sleeve 3200. A fluid is pumped into deliverydevice 1500 to evert sleeve 3200 past the pylorus and into theintestine.

FIG. 18C shows positioning cuff 3100 and sleeve 3200 in the stomach.Sleeve delivery device 1500 pulls cuff 3100 and sleeve 3200 into thestomach.

FIG. 18D shows releasing cuff 3100 and sleeve 3200 from sleeve deliverydevice 1500. Sleeve delivery device 1500 is then withdrawn.

FIG. 18E shows introducing catheter 2620 of anchor delivery device 2600.Catheter 2260 of anchor delivery device 2600 is introduced through theesophagus. An endoscope may be used for guidance and visualization.

FIG. 18F shows grasping cuff 3100. A grasping tool is introduced throughcatheter 2260 to grasp cuff 3100 and pull cuff 3100 over catheter 2260.Sled 2650 is introduced into catheter 2260 and used to hold cuff 3100.

FIG. 18G shows positioning cuff 3100 and sleeve 3200 at an attachmentpoint. Catheter 2620 pulls cuff 3100 and sleeve 3200 proximally up tothe gastroesophageal junction or other attachment points, some of whichare described elsewhere in the application.

FIG. 18H shows drawing a portion of a tissue wall into side port 2630 ofanchor delivery device 2620. A vacuum may be applied through the workinglumen of an endoscope placed in central lumen 2625.

FIG. 18I shows delivering tissue anchor 1300. Anchor delivery device2600 is used to deliver tissue anchors 1300 through cuff 3100 and thewall of the esophagus. Any suitable tissue anchor may also be used.Tissue marks made earlier by tissue marking device 1400 may be used as aguide.

FIG. 18J shows removing anchor delivery device 2600.

Alternatively, the method may include first deploying sleeve 3200without cuff 3100, then anchoring cuff 3100 at the attachment point, andthen grasping sleeve 3200 to attach sleeve 3200 to cuff 3100.

FIGS. 19A-19F show one embodiment of a method for exchanging a sleeve2200. The method may also be used for exchanging a sleeve 3200. In someembodiments, anchor delivery device 2600 may be used to replace tissueanchors 1300, such as those that may have pulled out of tissue, withoutnecessarily requiring exchange of sleeve 3200 and/or cuff 3100.

FIG. 19A shows a cuff 2100 and a sleeve 2200 implanted in an esophagus.A grasping tool is introduced into the esophagus.

FIG. 19B shows removing sleeve 2200. The grasping tool passes throughcuff 2100 to grasp sleeve 2200. The grasping tool may be configured topull drawstring 2241 to cinch ring 2240 of sleeve 2200. Halo 2260 orattachment elements 3260 may be cut. Sleeve 2200 is pulled out.

FIG. 19C shows introducing sleeve delivery device 1500. Sleeve deliverydevice 1500 passes through cuff 2100 and may position sleeve 2200 at ornear the pylorus. Sleeve delivery device 1500 may be introduced with orwithout an overtube. Sleeve delivery device 2500 or sleeve deliverydevice 3500 may also be used. An endoscope may be used for guidance andvisualization.

FIG. 19D shows deploying sleeve 2200. A fluid is pumped into deliverydevice 1500 to evert sleeve 2200 past the pylorus and into theintestine.

FIG. 19E shows positioning sleeve 2200 in the stomach. Sleeve deliverydevice 1500 pulls sleeve 2200 into the stomach.

FIG. 19F shows releasing sleeve 2200 from sleeve delivery device 1500.Sleeve delivery device 1500 is then withdrawn.

FIG. 19G shows grasping sleeve 2200. A grasping tool may be passedthrough cuff 2100 to grasp sleeve 2200. The grasping tool may beconfigured to pull drawstring 2241 to cinch ring 2240 of sleeve 2200.

FIG. 19H shows attaching sleeve 2200 to cuff 2100. The grasping toolpulls ring 2240 of sleeve 2200 into cuff 2100 so that ring 2240 may becoupled to retainer 2140. Halo 2260 or attachment elements 3260 may becoupled to hooks 2160 or attachment holes 3160, respectively.

While the foregoing has been with reference to particular embodiments ofthe invention, it will be appreciated by those skilled in the art thatchanges in these embodiments may be made without departing from theprinciples and spirit of the invention, including embodiments that donot provide all the features and benefits described herein. It will beunderstood by those skilled in the art that the present disclosureextends beyond the specifically disclosed embodiments to otheralternative or additional embodiments and/or uses and obviousmodifications and equivalents thereof. In addition, while a number ofvariations have been shown and described in varying detail, othermodifications, which are within the scope of the present disclosure,will be readily apparent to those of skill in the art based upon thisdisclosure. It is also contemplated that various combinations orsubcombinations of the specific features and aspects of the embodimentsmay be made and still fall within the scope of the present disclosure.Accordingly, it should be understood that various features and aspectsof the disclosed embodiments can be combined with or substituted for oneanother in order to form varying modes of the present disclosure. Thus,it is intended that the scope of the present disclosure herein disclosedshould not be limited by the particular disclosed embodiments describedabove. For all of the embodiments described above, the steps of anymethods need not be performed sequentially.

What is claimed is:
 1. A device for marking a tissue, the device comprising: a marking surface having a lumen, the lumen having an inlet and an outlet, the marking surface configured to contact the tissue, at least one opening formed in the marking surface; a dye source coupled to the inlet, the dye source having a dye; and a vacuum source coupled to the outlet, the vacuum source configured to create a vacuum in the lumen and create a seal between the opening and the tissue, the vacuum source configured to draw the dye through the inlet to at least partially fill the lumen with the dye and expose the tissue to the dye through the opening.
 2. The device of claim 1, further comprising: a rinse source coupled to the inlet, the rinse source having a rinse solution.
 3. The device of claim 2, wherein the rinse solution includes saline.
 4. The device of claim 2, wherein the rinse solution includes acetic acid.
 5. The device of claim 1, further comprising: a prep source coupled to the inlet, the prep source having a prep solution.
 6. The device of claim 5, wherein the prep solution includes isopropyl alcohol.
 7. The device of claim 1, wherein the dye source is coupled to the inlet through a manifold.
 8. The device of claim 1, wherein the dye includes gentian violet.
 9. The device of claim 1, wherein the marking surface includes a distal portion of a tube, the tube having an inlet lumen and an outlet lumen separated by a wall, and wherein the lumen of the marking surface includes a passage formed in the wall at the distal portion of the tube.
 10. The device of claim 1, wherein the marking surface is an exterior surface of a tube, and wherein the lumen of the marking surface is a lumen of the tube.
 11. A method for marking a tissue, the method comprising: placing a marking surface against the tissue, the marking surface having a lumen and at least one opening; applying a vacuum to an outlet of the lumen to draw a portion of the tissue against the opening; and drawing a dye with the vacuum through an inlet of the lumen to at least partially fill the lumen with the dye and allowing the dye to contact the portion of the tissue through the opening and mark the tissue.
 12. The method of claim 11, wherein drawing a dye includes maintaining the dye in the lumen for a period of time.
 13. The method of claim 11, further comprising: drawing a rinse solution with the vacuum through the inlet of the lumen to at least partially fill the lumen with the rinse solution and rinse the portion of the tissue.
 14. The method of claim 13, wherein drawing the rinse solution is performed before drawing the dye.
 15. The method of claim 13, wherein drawing the rinse solution is performed after drawing the dye.
 16. The method of claim 13, wherein the rinse solution includes saline.
 17. The method of claim 13, wherein the rinse solution includes acetic acid.
 18. The method of claim 11, further comprising: drawing a prep solution with the vacuum through the inlet of the lumen to at least partially fill the lumen with the prep solution and prepare the portion of the tissue, wherein drawing the prep solution is performed before drawing the dye.
 19. The method of claim 18, wherein the prep solution includes isopropyl alcohol.
 20. The method of claim 11, wherein the dye includes gentian violet. 